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Copyright © 2011. Nova Science Publishers, Incorporated. All rights reserved. Understanding Eating Disorders: Integrating Culture, Psychology and Biology, edited by Yael Latzer, Nova Science Publishers, Incorporated, 2011.
Copyright © 2011. Nova Science Publishers, Incorporated. All rights reserved. Understanding Eating Disorders: Integrating Culture, Psychology and Biology, edited by Yael Latzer, Nova Science Publishers, Incorporated, 2011.
HEALTH AND HUMAN DEVELOPMENT
Copyright © 2011. Nova Science Publishers, Incorporated. All rights reserved.
UNDERSTANDING EATING DISORDERS: INTEGRATING CULTURE, PSYCHOLOGY AND BIOLOGY
No part of this digital document may be reproduced, stored in a retrieval system or transmitted in any form or by any means. The publisher has taken reasonable care in the preparation of this digital document, but makes no expressed or implied warranty of any kind and assumes no responsibility for any errors or omissions. No liability is assumed for incidental or consequential damages in connection with or arising out of information contained herein. This digital document is sold with the clear understanding that the publisher is not engaged in rendering legal, medical or any other professional services.
Understanding Eating Disorders: Integrating Culture, Psychology and Biology, edited by Yael Latzer, Nova Science Publishers, Incorporated, 2011.
Health and Human Development Joav Merrick, Series Editor
Adolescent Behavior Research: International Perspectives Joav Merrick and Hatim A. Omar 2007. ISBN: 1-60021-649-8
Poverty and Children: A Public Health Concern Alexis Lieberman and Joav Merrick 2009. ISBN: 978-1-60741-140-6
Complementary Medicine Systems: Comparison and Integration Karl W. Kratky 2008. ISBN: 978-1-60456-475-4
Living on the Edge: The Mythical, Spiritual, and Philosophical Roots of Social Marginality Joseph Goodbread 2009. ISBN: 978-1-60741-162-8
Pain in Children and Youth Patricia Schofield and Joav Merrick 2008. ISBN: 978-1-60456-951-3
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Behavioral Pediatrics, 3rd Edition Donald E. Greydanus, Dilip R. Patel, Helen D. Pratt and Joseph L. Calles, Jr. 2009. ISBN: 978-1-60692-702-1 Behavioral Pediatrics, 3rd Edition Donald E. Greydanus, Dilip R. Patel, Helen D. Pratt and Joseph L. Calles, Jr. 2009. ISBN: 978-1-60876-630-7 (E-book) Health and Happiness from Meaningful Work: Research in Quality of Working Life Søren Ventegodt and Joav Merrick 2009. ISBN: 978-1-60692-820-2 Obesity and Adolescence: A Public Health Concern Hatim A. Omar, Donald E. Greydanus, Dilip R. Patel and Joav Merrick 2009. ISBN: 978-1-60456-821-9
Challenges in Adolescent Health: An Australian Perspective David Bennett, Susan Towns, Elizabeth Elliott and Joav Merrick (Editors) 2009. ISBN: 978-1-60741-616-6 Challenges in Adolescent Health: An Australian Perspective David Bennett, Susan Towns, Elizabeth Elliott and Joav Merrick (Editors) 2009. ISBN: 978-1-61668-240-8 (E-book) Alcohol-Related Cognitive Disorders: Research and Clinical Perspectives Leo Sher, Isack Kandel and Joav Merrick 2009. ISBN: 978-1-60741-730-9 Alcohol-Related Cognitive Disorders: Research and Clinical Perspectives Leo Sher, Isack Kandel and Joav Merrick 2009. ISBN: 978-1-60876-623-9 (E-book) Advances in Environmental Health Effects of Toxigenic Mold and Mycotoxins- Volume 1 Ebere Cyril Anyanwu 2010. ISBN: 978-1-60741-953-2
Understanding Eating Disorders: Integrating Culture, Psychology and Biology, edited by Yael Latzer, Nova Science Publishers, Incorporated, 2011.
Children and Pain Patricia Schofield and Joav Merrick (Editors) 2009. ISBN: 978-1-60876-020-6 Child Rural Health: International Aspects Erica Bell and Joav Merrick (Editors) 2010. ISBN: 978-1-60876-357-3 Conceptualizing Behavior in Health and Social Research: A Practical Guide to Data Analysis Said Shahtahmasebi and Damon Berridge 2010. ISBN: 978-1-60876-383-2
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Chance Action and Therapy. The Playful Way of Changing Uri Wernik 2010. ISBN: 978-1-60876-393-1 Adolescence and Chronic Illness. A Public Health Concern Hatim Omar, Donald E. Greydanus, Dilip R. Patel and Joav Merrick (Editors) 2010. ISBN: 978-1-60876-628-4 Adolescence and Sports Dilip R. Patel, Donald E. Greydanus, Hatim Omar and Joav Merrick (Editors) 2010. ISBN: 978-1-60876 International Aspects of Child Abuse and Neglect Howard Dubowitz and Joav Merrick (Editors) 2010. ISBN: 978-1-60876-703-8
Positive Youth Development: Evaluation and Future Directions in a Chinese Context Daniel T.L. Shek, Hing Keung Ma and Joav Merrick (Editors) 2010. ISBN: 978-1-60876-830-1 Positive Youth Development: Evaluation and Future Directions in a Chinese Context Daniel T.L. Shek, Hing Keung Ma and Joav Merrick (Editors) 2010. ISBN: 978-1-61668-376-4 (E-book) Positive Youth Development: Implementation of a Youth Program in a Chinese Context Daniel T.L Shek, Hing Keung Ma and Joav Merrick (Editors) 2010. ISBN: 978-1-61668-230-9 Pediatric and Adolescent Sexuality and Gynecology: Principles for the Primary Care Clinician Hatim A. Omar, Donald E. Greydanus, Artemis K. Tsitsika, Dilip R. Patel and Joav Merrick (Editors) 2010. ISBN: 978-1-60876-735-9 Understanding Eating Disorders: Integrating Culture, Psychology and Biology Yael Latzer, Joav Merrick and Daniel Stein (Editors) 2010. ISBN: 978-1-61668-261-3. (softcover) 2010. ISBN 978-1-61728-298-0 (hardcover) Advanced Cancer Pain and Quality of Life Edward Chow and Joav Merrick (Editors) 2010. ISBN: 978-1-61668-207-1
Understanding Eating Disorders: Integrating Culture, Psychology and Biology, edited by Yael Latzer, Nova Science Publishers, Incorporated, 2011.
Social and Cultural Psychiatry Experience from the Caribbean Region Hari D. Maharajh and Joav Merrick (Editors) 2010. ISBN: 978-1-61668-506-5 Social and Cultural Psychiatry Experience from the Caribbean Region Hari D. Maharajh and Joav Merrick (Editors) 2010. ISBN: 978-1-61728-088-7 (E-book) Bone and Brain Metastases: Advances in Research and Treatment Arjun Sahgal, Edward Chow and Joav Merrick (Editors) 2010. ISBN: 978-1-61668-365-8
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Bone and Brain Metastases: Advances in Research and Treatment Arjun Sahgal, Edward Chow and Joav Merrick (Editors) 2010. ISBN: 978-1-61728-085-6 (E-book) Environment, Mood Disorders and Suicide Teodor T. Postolache and Joav Merrick (Editors) 2010. ISBN: 978-1-61668-505-8 Cancer in Children and Adults with Intellectual Disabilities: Current Research Aspects Daniel Satgé and Joav Merrick (Editors) 2011. ISBN: 978-1-61761-856-7 Self-Management and the Health Care Consumer Peter William Harvey and Joav Merrick (Editors) 2011. ISBN: 978-1-61761-796-6
Sexology from a Holistic Point of View Soren Ventegodt and Joav Merrick (Editors) 2011. ISBN: 978-1-61761-859-8 Principles of Holistic Psychiatry: A Textbook on Holistic Medicine for Mental Disorders Soren Ventegodt and Joav Merrick (Editors) 2011. ISBN: 978-1-61761-940-3 International Aspects of Child Abuse and Neglect Howard Dubowitzand Joav Merrick (Editors) 2011. ISBN: 978-1-61122-049-0 Clinical Aspects of Psychopharmacology in Childhood and Adolescence Donald E. Greydanus, Joseph L. Calles Jr., Dilip P. Patel, Ahsan Nazeer and Joav Merrick (Editors) 2011. ISBN: 978-1-61122-135-0 Climate Change and Rural Child Health Erica Bell,Bastian M. Seidel and Joav Merrick (Editors) 2011. ISBN: 978-1-61122-640-9 Rural Medical Education: Practical Strategies Erica Bell, Craig Zimitat and Joav Merrick (Editors) 2011. ISBN: 978-1-61122-649-2 Chance Action and Therapy: The Playful Way of Changing Uri Wernik and Joav Merrick (Editors) 2011. ISBN: 978-1-61122-987-5 Public Health Yearbook 2009 Joav Merrick (Editor) 2011. ISBN: 978-1-61668-911-7
Understanding Eating Disorders: Integrating Culture, Psychology and Biology, edited by Yael Latzer, Nova Science Publishers, Incorporated, 2011.
HEALTH AND HUMAN DEVELOPMENT
UNDERSTANDING EATING DISORDERS: INTEGRATING CULTURE, PSYCHOLOGY AND BIOLOGY
YAEL LATZER, JOAV MERRICK AND
Copyright © 2011. Nova Science Publishers, Incorporated. All rights reserved.
DANIEL STEIN EDITORS
Nova Science Publishers, Inc. New York
Understanding Eating Disorders: Integrating Culture, Psychology and Biology, edited by Yael Latzer, Nova Science Publishers, Incorporated, 2011.
Copyright © 2011 by Nova Science Publishers, Inc. All rights reserved. No part of this book may be reproduced, stored in a retrieval system or transmitted in any form or by any means: electronic, electrostatic, magnetic, tape, mechanical photocopying, recording or otherwise without the written permission of the Publisher. For permission to use material from this book please contact us: Telephone 631-231-7269; Fax 631-231-8175 Web Site: http://www.novapublishers.com NOTICE TO THE READER The Publisher has taken reasonable care in the preparation of this book, but makes no expressed or implied warranty of any kind and assumes no responsibility for any errors or omissions. No liability is assumed for incidental or consequential damages in connection with or arising out of information contained in this book. The Publisher shall not be liable for any special, consequential, or exemplary damages resulting, in whole or in part, from the readers’ use of, or reliance upon, this material.
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Library of Congress Cataloging-in-Publication Data Understanding eating disorders : integrating culture, psychology and biology / editors, Yael Latzer, Joav Merrick, Daniel Stein. p. ; cm. -- (Health and human development) Includes bibliographical references and index. ISBN 978-1-61942-054-0 (e-book) 1. Eating disorders. I. Latzer, Yael. II. Merrick, Joav, 1950- III. Stein, Daniel, 1949- IV. Series: Health and human development series. [DNLM: 1. Eating Disorders. WM 175 U554 2010] RC552.E18U55 2010 616.85'26--dc22 2010015635
Published by Nova Science Publishers, Inc.
New York
Understanding Eating Disorders: Integrating Culture, Psychology and Biology, edited by Yael Latzer, Nova Science Publishers, Incorporated, 2011.
Contents INTRODUCTION Eating disorders: Diagnosis, Epidemiology, Etiology and Prevention Yael Latzer, Joav Merrick and Daniel Stein
1
Copyright © 2011. Nova Science Publishers, Incorporated. All rights reserved.
SECTION ONE: OVERVIEW Chapter 1
Why DSM V Needs to Consider a Staging Model for Anorexia Nervosa Sarah Maguire, Stephen Touyz,Lois J Surgenor, Hubert Lacey, and Daniel Le Grange
Chapter 2
Night Eating Syndrome Yael Latzer, Kelly C Allison, Orna Tzischinsky, and Piergiuseppe Vinai
Chapter 3
Clinical and Diagnostic Characteristics of Eating Disorders in Children and Adolescents Jenny Nicholson and Dasha Nicholls
15
29
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SECTION TWO: HISTORY AND CULTURE Chapter 4
A Historical Background to Current Formulations of Eating Disorders Eliezer Witztum, Yael Latzer and Daniel Stein
61
Chapter 5
Eating Disorders: Global Marker of Change Melanie A Katzman
77
Chapter 6
Eating-related Psychopathology in Israel: Nationwide Perspectives and Focusing on Specific Populations Yael Latzer, Eliezer Witztum and Daniel Stein
Chapter 7
A Historical, Cultural and Empirical look at Eating Disorders and Religiosity among Jewish Women Sarah L Weinberger-Litman, Yael Latzer and Daniel Stein
Understanding Eating Disorders: Integrating Culture, Psychology and Biology, edited by Yael Latzer, Nova Science Publishers, Incorporated, 2011.
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109
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Contents
SECTION THREE: ETIOLOGY Chapter 8
Eating disorders in the Mediterranean world Giovanni M Ruggiero and Sandra Sassaroli
125
Chapter 9
Genetic Aspects of Anorexia Nervosa Andrea Poyastro Pinheiro, Tammy Root and Cynthia M Bulik
143
Chapter 10
The Neurobiology of Eating Disorders Guido KW Frank and Leah M Jappe
157
Chapter 11
Hemispheric Asymmetry in Eating Disorders Zohar Eviatar and Yael Latzer
169
Chapter 12
Self Psychology in the Treatment of Anorexia Nervosa and Bulimia Nervosa Eytan Bachar and Yekutiel Samet
181
Chapter 13
Implicit Measures: Implicit Personality Characteristics and Implicit Processes in Eating Disorders Lily Rothschild-Yakar and Daniel Stein
197
Chapter 14
Cognitive Orientation and Eating Disorders Shulamith Kreitler
Chapter 15
Perspectives on the Role of Families in the Development, Maintenance and Treatment of Eating Disorders: From Blame to Empowerment 225 Alison Darcy and James Lock
209
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SECTION FOUR: PREVENTION Chapter 16
The Case for Universal-Selective Eating Disorders Prevention Programs Michael P Levine and Linda Smolak
Chapter 17
Parenting Teens with a Healthy Body and a Healthy Body Image Dianne Neumark-Sztainer
Chapter 18
Parenting and Children’s Eating Patterns: Examining Control in a Broader Context Sheryl O Hughes, Teresia M O’Connorand Thomas G Power
Chapter 19
Cultural Sensitivity and Eating Disorders Primary Prevention: The Adaptation of an Effective Primary Prevention Program for Jewish Girls Catherine Steiner-Adair
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SECTION FIVE: ACKNOWLEDGMENTS Chapter 20
About the Editors
285
Chapter 21
About the Institute for the Treatment and Study of Eating Disorders, Division of Psychiatry, Rambam Medical Center, Haifa, Israel
287
Understanding Eating Disorders: Integrating Culture, Psychology and Biology, edited by Yael Latzer, Nova Science Publishers, Incorporated, 2011.
Contents Chapter 22
ix
About the Pediatric Psychosomatic Department, Edmond and Lily Safra Children’s Hospital, Chaim Sheba Medical Center, Tel Hashomer, Israel
289
Chapter 23
About the National Institute of Child Health and Human Development in Israel
291
Chapter 24
About the “Health And Human Development” Book Series
295
SECTION SIX: INDEX
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Index
Understanding Eating Disorders: Integrating Culture, Psychology and Biology, edited by Yael Latzer, Nova Science Publishers, Incorporated, 2011.
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Copyright © 2011. Nova Science Publishers, Incorporated. All rights reserved. Understanding Eating Disorders: Integrating Culture, Psychology and Biology, edited by Yael Latzer, Nova Science Publishers, Incorporated, 2011.
In: Understanding Eating Disorders Editors: Yael Latzer, Joav Merrick, Daniel Stein
ISBN 978-1-61728-298-0 © 2011 Nova Science Publishers, Inc.
Introduction Eating Disorders: Diagnosis, Epidemiology, Etiology and Prevention
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Yael Latzer1, DSc, Joav Merrick2, MD, MMedSci, DMSc and Daniel Stein3, MD Eating disorders (EDs) are considered a major disease of the modern world, being among the most prevailing public health problems in female adolescents and young adults in recent decades, and reaching in many Western countries an epidemic proportion (1). The last two decades have envisioned an abundance of research in many aspects related to EDs. Nevertheless, EDs are still highly misunderstood disorders that often raise a host of negative emotions such as bewilderment, mistrust and fear. These reactions are likely the result of failing to grasp why individuals would not comply with the basic universal need of eating, or put such an emphasis on weight and appearance that renders them more important than anything else in life (2). ED patients, their families, treatment providers and the society in which they live are thus still faced with a multitude of problems, ranging from detrimental myths and prejudices to the interference of political considerations with respect to the budget provided for treatment, research, and prevention. These issues are of particular relevance in Israel. This because on the one hand Israeli male and female youngsters are troubled since the 1990th with eating-related disturbances to a greater extent than almost any other Western industrialized country, raising critical questions about their emotional well-being. Yet, the funding provided for the treatment of 1 Institute for the Treatment and Study of Eating Disorders, Division of Psychiatry, Rambam, Health Care Campus, Haifa, Israel, affiliated with the Faculty of Social Welfare and Health Sciences, Haifa University, Israel. Email:[email protected]. 2 Director, National Institute of Child Health and Human Development, Medical Director, Health Services, Ministry of Social Affairs, Jerusalem, Israel and Kentucky Children’s Hospital, University of Kentucky, Lexington, United States of America. [email protected]. 3 Pediatric Psychosomatic Department, Edmond and Lily Safra Children’s Hospital, Chaim Sheba Medical Center, Tel Hashomer, affiliated with the Sackler Faculty of Medicine, Tel Aviv University, Israel. E-mail: [email protected].
Understanding Eating Disorders: Integrating Culture, Psychology and Biology, edited by Yael Latzer, Nova Science Publishers, Incorporated, 2011.
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Yael Latzer, Joav Merrick and Daniel Stein
EDs in Israel is scarce relative to almost all other Western industrialized countries (3). This has led us to combine renowned researchers from around the globe with Israeli researchers in our endeavor to tackle important, often still unanswered, issues in the field of EDs. We have been extremely fortunate to receive the contribution of many important authorities, and this is one opportunity to thank them for their efforts and cooperation. The upcoming book is the first of two. It focuses primarily on historical and sociocultural aspects, diagnostic concerns, epidemiology, etiological considerations and prevention. The second book will be dedicated to the treatment of EDs. In the upcoming editorial we have made an attempt to provide the reader with a short, up-to-date, summary of the issues that will be extensively dealt with in this book
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Diagnosis The different EDs are grouped into several well-known clinical entities. According to the most updated diagnostic criteria of the American Psychiatric Association, the Diagnostic and Statistical Manual of Mental Disorders, 4th edition, Text Revised (DSM-IV-TR (4), the different EDs are categorized into anorexia nervosa (AN), bulimia nervosa (BN), binge eating disorder (BED) and eating disorders not otherwise specified (ED-NOS), also termed partial, or sub-clinical, ED syndromes. The latter group includes a variety of maladaptive eatingrelated preoccupations and behaviors that do not reach the severity of full-blown EDs (5), but are distinct from mere dieting and disturbances in body image in having the potential to induce significant morbidity. Furthermore, almost half of individuals with ED-NOS may progress to the full syndrome within several years (6). Binge Eating Disorder (BED) is currently considered a separate provisional category in the DSM-IV-TR (4), although formally it is still diagnosed within the ED-NOS spectrum. EDs can be differentiated according to weight (low in AN, normal in BN and often overweight in BED), and the presence or absence of bingeing and weight reduction compensatory purging behaviors (vomiting, or use of supposedly anti-weight medications, primarily, but not only, laxatives) (7). Both classifications are subject to considerable controversy (8), as many patients may fluctuate among the different ED categories during the course of their illness (9). Another caveat relates to the considerable similarity found between fully-diagnosed AN patients and restrictive ED-NOS patients who share all the diagnostic criteria of AN with the exception of amenorrhea (5), not to mention the growing evidence in recent years of an elevated incidence of AN in prepubertal girls and in boys (1).
Epidemiology AN appears primarily during adolescence, whereas BN and BED appear primarily in young adults; all EDs occur primarily in females with 5-10% of the patients being male (1). The lifetime prevalence of AN, BN and BED among females in Western countries is estimated to be between 0.3-1.20%, 1-1.5% and 3-3.5%, respectively, and among males 0.3%, 0.7% and 2% respectively (1,10,11). The prevalence of partial ED (ED-NOS) syndromes is in the range of 3 to 22% (5), depending on whether the disorders are diagnosed according to standardized
Understanding Eating Disorders: Integrating Culture, Psychology and Biology, edited by Yael Latzer, Nova Science Publishers, Incorporated, 2011.
Introduction
3
clinical interviews (lower prevalence) or standardized questionnaires (higher prevalence). Although the prevalence rate for both AN and BN is lower in non-Western than in Western countries (there are yet no sufficient data for BED or ED-NOS), it is gradually increasing in non-Western countries in recent years (12). Both AN and BN have shown an increase in their incidence in the second half of the 20th century, particularly among young women (1), although at least some studies argue that what is raised is actually the frequency of treatment use (13). The standardized mortality ratios in AN are between 5-10 times greater than in normal controls (14), and considerably higher than those reported for most other psychiatric disturbances, being the highest in bingeing-purging type AN. By contrast, relatively low mortality rates (0.3-3 times greater than controls) have been reported in BN (14). AN and BN represent chronic disorders with recovery occurring mostly after 4-10 years from the start of the illness (15,16). Recovery in terms of maintaining normal weight and regular menstrual periods and abstaining from restricting, bingeing and purging behaviors for at least one year occurs in 40-55% of AN (15) and BN patients (16,17) and a subclinical course is still present in 30-35% of these patients. Despite treatment, around 20% of AN (15) and BN (16) patients will show a chronic non-remitting course over time. Relapse rate is high, with 30-50% of AN and BN patients likely relapsing within a few months to several years (16,18).
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Etiology EDs likely reflect complex, inter-dependent, multi-dimensional causalities (19). Dieting behaviors may be propelled into a full-blown disorder by a complex interaction of antecedent genetic, biological, psychological, familial and social vulnerabilities with a host of environmental influences (19). The study of the etiology of EDs is highly problematic because of their relative rarity, necessitating extremely large cohorts, the low rate of people who meet stringent diagnostic criteria for EDs seen in mental health care, the confounding influences of malnutrition and erratic consummatory patterns on the assessment of acutely-ill patients, the influence of socio-cultural parameters on the presentation of an ED, and the interference of political considerations with the study of these disorders (10,13,19).
1. Socio-cultural aspects Traditionally, EDs have been conceptualized to represent a culture-dependent syndrome, namely a syndrome that cannot be understood separated from its cultural context, and that is restricted to a limited number of cultures by virtue of psychosocial factors (20). Studies supporting this view have flourished between the 1960th and the 1980th, emphasizing that the increase in the frequency of EDs in young women in Western cultures found during these years is the result of a similar increase in the influence of socio-cultural norms such as the importance of slimness, youth, personal achievement, individualism, and women’s selfdefinition (21). Many factors have been suggested in support of a significant socio-cultural contribution to the predisposition to an ED, including the different rates and presentations of
Understanding Eating Disorders: Integrating Culture, Psychology and Biology, edited by Yael Latzer, Nova Science Publishers, Incorporated, 2011.
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Yael Latzer, Joav Merrick and Daniel Stein
EDs in different cultures (Western vs. non-Western cultures) and populations (females vs. males), the association between the new appearance of EDs in different countries and the recent exposure of these countries to Westernized influences, and the different internalization of norms related to weight and shape in young women at risk for developing future EDs, compared with healthy girls (21). More recent studies, however, cast doubt as to the definition of AN as culturally dependent, as the current prevalence of AN in many non-Westernized countries is often similar to that found in Western countries, and the recent increase in its incidence in Western countries likely reflects greater use of treatment facilities rather than being a genuine change (13). Although this is not yet the case for BN (13), the constant increase in its rate in nonWestern cultures in recent years (11), may cast some doubt also with respect to a putative socio-cultural causation in BN. In line with these reservations, recent studies, highlighting the considerable influence of genetic vulnerabilities in the predisposition to an ED, and the relative infrequency of full-blown EDs in comparison to the high rate of females that are dissatisfied with their weight and preoccupied with dieting, signify the limited role of sociocultural parameters in the predisposition to an ED (13). Nevertheless, alongside those researchers minimizing the role of culture in the predisposition to an ED (13,22), other suggest to change the focus of this association, rather than disregarding completely the wealthy literature associating EDs with culture (23). Thus recent theories suggest that EDs may represent a cultural byproduct of modernity that cuts across geographic and economic lines in vulnerable individuals, rather than being a strictly Western phenomenon (23). EDs are attributed in this context to a combination of socioeconomic developments, including the rapidly changing roles of women, the sociocultural emphasis on thinness that currently cuts across different cultures, and the shift in eating patterns resulting from the recent advent of modernity and change in food availability in many regions across the globe (23). Other authors have “borrowed” the concept of idiom of distress to the realm of EDs (24). This concept relates to the likelihood of people in different cultures to express their distress and deal with its consequences in different ways that reflect the meaning that the culture gives not only to the distress itself, but also to the mode in which it is expressed. Accordingly, EDs may be regarded as an idiom of distress, in that in many (although not all) societies and eras, and also in our modern times, they can serve women as a mean to express their pain, to build a sense of identity in front of considerable external pressure and internal confusion, and to cope with social pressures related to individuality, autonomy, equality, and social position (24).
2. Genetic and biological considerations Family history studies show elevated rates of decreased or elevated weight, as well as of AN, BN, and ED-NOS in 1st degree relatives of patients with AN and BN (25). These studies, although informative, do not allow the separation of genetic and environmental influences in the predisposition to an ED. By contrast, twin studies support the major role of genetic factors in the development of EDs, in showing elevated concordance rates of AN, BN, and/or EDNOS in monozygotic twins in whom the afflicted twin has AN or BN, compared to dyzygotic twins (10). According to these studies, the heritability estimates for AN and BN are in the range of 0.54-0.80 (10). Recent studies suggest that what is genetically transmitted are
Understanding Eating Disorders: Integrating Culture, Psychology and Biology, edited by Yael Latzer, Nova Science Publishers, Incorporated, 2011.
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Introduction
5
underlying temperamental liabilities comorbid with EDs, for example perfectionism, need for organization, and reward dependence (26). The recent application of molecular genetic studies in EDs provides an opportunity to assess the role of specific genes or gene-groups in the predisposition to an ED. Two such genetic analytic approaches currently exist, genome-wide linkage analyses and candidate gene association studies. Linkage studies require the inclusion of several members of a family for each analysis. In these studies, different polymorphisms of genetic markers located in relevant chromosomal regions are genotyped, to identify the variants of interest. In candidate gene association studies, cases ill with an ED are compared with non-ED controls for the identification of the gene variants of interest. Both approaches have demonstrated some, although not definite, findings for some genes in the predisposition to an ED. In linkage analyses, these findings relate to specific serotonin (5HT) receptor and opioid receptor genes located in specific chromosomes [chromosomes 1,2,3], whereas in case control studies, these relate to serotonergic genes, dopaminergic genes, genes related to neuropeptides involved in feeding regulation, and brain-derived neurotrophic factor genes (BDNF). The relevance of these findings is critically analyzed in the up-to-date review study about genetics in EDs in the present book (27). Central nervous system (CNS) neuropetides, including neurosteroids, opioids, neuropeptide-Y, peptide Y, vasopressin, oxytocin, coleycystokinin, leptin and adiponectin, and CNS neurotransmitters (serotonin, dopamine, and norepinephrine) may all play an important role in the regulation of feeding behavior. However, their role in the predisposition to an ED is still unclear. As most of the neuropeptide alterations apparent during symptomatic episodes of AN and BN tend to normalize upon physical stabilization, they likely represent consequences of malnutrition and maladaptive consummatory patterns, rather than their premorbid causes (22). Recent neuroimaging studies have shown serotonin alterations in cingulated limbic structures, and in frontal, temporal, and parietal cortical regions (28), and dopamine alterations in the antro-ventral striatum and dorsal caudate areas of the basal ganglia (29), that persist also in patients recovered from AN, and in some cases also from BN. Findings persisting in recovered patients may be a consequence of prior illness and explain why these patients still suffer from some physiological, behavioral and psychological handicaps. Alternatively, the finding of neurotransmitter alterations in the absence of confounding nutritional influences raises the likelihood of them representing in some cases long-standing, premorbid traits (23). The elevated dopaminergic and serotonergic activity in recovered ED patients may potentially account not only for feeding-behavior dysfunctions, but also for personality traits found elevated in recovered patients, i.e., potentially predisposing to an ED. In recovered restricting AN patients, these traits include elevated harm-avoidance (reflecting resistance to changes), behavioral inhibition, rigidity, perfectionism, obsessionality, and negative emotionality, particularly anxiety (22,30,31). In the case of BN, patients in the acute stage of the disorder demonstrate elevated rates of personality traits indicative of impulsivity, reactivity to stress, affective dysregulation, and novelty seeking (22,30,31). Recovered patients show significant attenuation of these traits, reflecting the influence of the erratic consummatory and emotional patterns in symptomatic BN patients - in which restraint and disinhibition often alternate - on personality presentation. Moreover, recovered BN show elevated rates of personality traits traditionally considered indicative of restricting AN, (30,31), including negative emotionality, harm avoidance, ineffectiveness, obsessionality,
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Yael Latzer, Joav Merrick and Daniel Stein
restraint and perfectionism, raising the likelihood of some shared predisposing vulnerabilities for both disorders (22).
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3. Psychological considerations The study of psychological factors potentially predisposing to EDs is subject to considerable conceptual and methodological controversies and ambiguities. Each model relates to the etiology of EDs - as it does with any psychopathology of a putative psycho-developmental origin - according to specific inbuilt conceptualizations that are generated from treatments of already-ill individuals. For example, classical psychoanalytic authors have hypothesized that the upsurge during adolescence of sexuality-related fears might lead the future to be AN patient to a regression from oedipal to pre-oedipal eating-related oral anxieties (32). The inherent problems with such models are that hypotheses about predisposing psychological factors are derived from findings in patients who are severely ill not only psychologically but also physiologically when analyzed, and that these models cannot be subject to rigorous research. Despite these limitations, the merit of any psychological model is that it may assist at least some ED patients (and their therapists) in understanding that their suffering has some relevant deep-rooted personal meaning; this, in turn, may offer an opportunity towards selfacceptance, and/or readiness for change. In this respect, the pioneering insights of Bruch (33) have led to the conceptualization of EDs in terms of severe pervasive ego (characterological) pathology, manifested by faulty reality testing, severe disturbances in body image and in the identification of bodily and emotional states, needs, and feelings, faulty perception of interpersonal relationships, and an all-pervasive sense of ineffectiveness and lack of autonomy (33). Others have highlighted the role of faulty regulation of impulses and affects (22), and of maladaptive social capacities (34), as predisposing some individuals to develop and maintain an ED. Again, whereas there is compelling evidence to suggest that the pervasive psychopathology in EDs can be the result of faulty ego capabilities, this has, nevertheless, not been substantiated empirically. Two psychological models have gained considerable relevance in recent years. The cognitive theory assumes that a complex multidirectional model may tie the development of an ED to specific maladaptive cognitions and behaviors. Accordingly, inborn dysfunctional core cognitions related to severe lack of self-esteem may require an exaggerated inclination towards cognitive-related dichotomy, self-control, rigidity, and perfectionism (22,31) to correct such a pervasive sense of worthlessness. These cognitive distortions, may, in turn, lead in vulnerable individuals to the development and perpetuation of complex interdependent interactions between extreme concern with weight and shape and the perusing of relentless strict dieting, likely culminating in diverse ED-related presentations (35). The recently modified transdiagonistic cognitive formulation (36) further postulates that the interaction of maladaptive cognitions and behaviors related to eating, weight and physical appearance with certain core ED-related personality configurations indicative of elevated perfectionism, low self-esteem, intolerance of intense affects, and deficient social capacities may be of particular relevance in vulnerable individuals in the development and maintenance of diverse ED presentations (36,37).
Understanding Eating Disorders: Integrating Culture, Psychology and Biology, edited by Yael Latzer, Nova Science Publishers, Incorporated, 2011.
Introduction
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The self-psychology model also ascribes an important role to an early pervasive disturbance in self-esteem in the predisposition to an ED, but the focus of this model is highly different in comparison to cognitive conceptualizations. According to self-psychology, in an attempt to enhance a vulnerable sense of self-worth, future to be ED patients are often inclined towards fulfilling the needs of significant others and giving-up their own, being convinced that they do not deserve others to serve as their putative self-objects (38,39). With time, despite all their efforts, these individuals are inclined to feel misunderstood, misperceived and unloved by others, leading them to gradually withdraw from human beings as self-objects, relying, in turn, on food, or on actively refraining from food, as fulfilling replacing self-objects. In the case of BN and BED, food may serve to fill an intolerable sense of emptiness and void, whereas in restricting AN patients, the capability and choice to refrain from eating may be of considerable importance in enhancing self-worth and self-acceptance (38,39).
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4. Family-related considerations Traditional models have put a great emphasis on the putative influence of the family in the predisposition to an ED. Minuchin (40) in the mid 1970th, in his conceptualizations about psychosomatic families, of which AN has been viewed as a prototype, has emphasized that the constellation of several important familial characteristics might predispose to the development of an ED. These traits include the rigidity of the family boundaries, the presence of pervasive enmeshment and overprotection in intra-familial and intergenerational relationships, and the role of the child's ED in maintaining the inclination of the family to avoid resolution of family conflicts. Similarly, systematic family theorists (41) have suggested that a family may have a potential to predispose to an ED if it becomes a rigidly organized interactional system in which the symptoms of illness become a powerful homeostatic mechanism resistant to change from the outside. These and similar theories have been severely criticized in later years, as many families with the aforementioned characteristics have no evidence of an ED, and many ED families do not share these characteristics. Secondly, whereas the “psycho-somatic family” has been traditionally associated with the development of AN, most studies have found no evidence supporting any specific family constellation in the predisposition to other ED types. Thirdly, these hypotheses have been developed according to studies in acutely ill patients, not taking into consideration the considerable effect of a chronic illness on the family's well-being and overall functioning. Most importantly, such conceptualizations have lead, even if inadvertently, to severe blame from many others, including mental health authorities, onto the family of an ED patient. We, on the other hand, agree with many current researchers, who suggest that families of ED patients may actually have an exceptionally important protective role in promoting healthier attitudes and behaviors towards eating, weight and shape, and in supporting their offspring who often experiences weight-related teasing and criticisms (42). In this respect, the family support is likely of considerable importance in empowering ED patients in their endeavors towards change. Currently it is conceived that shared environmental influences, namely experiences shared by all family members, have only a limited influence in the development of an ED. By contrast, according to twin studies, non-shared environmental influences, namely those
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experiences that are unique to one sibling and not shared by other siblings reared in the same family, have been found to account for 0.17-0.46 of the variance in the development of both AN and BN (43). Initial data indicate that disturbances in parental relationships occurring in critical years in the development of one sibling but not necessarily in others, coupled with body weight teasing, peer group experiences, and adverse life events, may account in part for the development of eating pathology in one sibling versus another (43).
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Prevention The issue of prevention seems to raise an abundance of disputes and disagreements, not only with respect to what constitutes “right” and “wrong” interventions, but also with respect to the merit/risk/justification of prevention programs per se. In the field of EDs, controversies do exist with respect to the advantages and disadvantages of secondary programs targeted at specific populations considered at high risk to develop an ED vs. primary ED-related prevention programs implemented for all youngsters (44,45). It is usually accepted that secondary programs are more effective for adolescents older than 15, whereas primary programs, may be more effective for early adolescents (ages 11-13) and for children under the age of 11 years (45). In the younger age groups, adequate interventions have the potential to intervene with precursors for the development of EDs, both personal precursors, e.g., body dissatisfaction, weight concerns, and/or dieting behaviors, and general socio-cultural precursors, primarily exposure to the thin body ideal, peer teasing, sexual harassment, and parental weight and shape-related comments. Moreover, primary prevention programs can potentially reduce the risk of developing a teen “sub-culture” in which girls are highly involved in comparing weight and shape, exchanging diets, and exercising disordered eating behaviors (45). ED-related prevention programs have been developed in many Westernized countries in Europe and North America, including in Israel (47). Nevertheless, there is yet no agreement concerning the long-term effects of these programs (48). Some studies show post-treatment improvement, that in some cases may continues for 6-12 months. Other studies, on the other hand, have failed to show sustained post-intervention change. Several recent meta-analyses of controlled studies (44,49) show mostly an improvement in relevant knowledge, reduction in ED-related risk factors, and small positive changes in general eating abnormalities, dieting, and thin-ideal internalization. Most changes tend to persist at follow-up. Although some studies have cautioned that preventive interventions might worsen eating- related attitudes and behaviors, this has not been found in careful reviews of the relevant literature (44). Despite these positive findings, some authorities still claim that prevention programs involving only children and adolescents have a limited effect, at best. Efforts should be rather geared towards altering the actual environments (home, school) in which children may develop problematic eating, and promote eating-related protective factors, such as adequate parental modeling with respect to eating- and weight-related attitudes, and the provision of healthy food and appropriate physical exercising (50) Alternatively, efforts should be primarily carried out at the level of government policies, relating to such concerns as the abundance of weight-related advertisements in the media, or the provision of adequate
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Introduction
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resources to promote the value of feminism and empowerment in young girls, to name a few (45).
Conclusions This book includes nineteen chapters, where the first three relate to important issues with respect to the diagnosis and classification of EDs. These are followed by five chapters on historical and socio-cultural aspects, three chapters on genetics and biology, and four chapters dedicated to psychological considerations, including the place of the family in EDs. The last four chapters relate to diverse issues in the field of prevention. We have attempted to edit a multi-faceted, intriguing, yet balanced book. In line with this attempt, the introduction aims to provide up-to-date information with respect to the contents of the book, yet to point towards important controversies dealt in depth by other authors. We thank once again all authors contributing to this endeavor and making it possible, hoping that it provides the interested reader with valuable information, fruitful insight, and enriching ideas.
References
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[1]
Hoek HW. Incidence, prevalence and mortality of anorexia nervosa and other eating disorders. Curr Opin Psychiatry 2006;19:389-94. [2] Golan M, Yaroslavski A, Stein D. Managing eating disorders: Countertransference and other dynamic processes in the therapeutic milieu. Int J Child Adolesc Health 2009;2:21327. [3] Latzer Y, Witztum E, Stein D. Eating disorders as an idiom of distress: The Israeli perspective. Eur J Eating Disord 2008;16:361-74. [4] American Psychiatric Association. Diagnostic and statistical manual of mental disorders, 4th ed. Text revised (DSM-IV-TR). Washington, DC: APA, 2000. [5] Shisslak CM, Crayo M, Estes LS. The spectrum of eating disturbances. Int J Eat Disord 1995;18:209-19. [6] Fairburn CG, Harrison PJ. Eating disorders. Lancet 2003;361:407-16. [7] Williamson DA, Gleaves DH, Stewart TM. Categorical versus dimensional models of eating disorders: an examination of the evidence. Int J Eat Disord 2005;37:1-10. [8] Wonderlich SA, Crosby RD, Mitchell JE, Engel SG. Testing the validity of eating disorder diagnoses. Int J Eat Disord 2007; 40S:S40-5 [9] Eddy KT, Dorer DJ, Franko DL, Tahilani K, Thompson-Brenner H, Herzog DB. Diagnostic crossover in anorexia nervosa and bulimia nervosa: implications for DSM-IV. Am J Psychiatry 2008;165:245-50. [10] Bulik CM, Sullivan PF, Tozzi F, Furberg H, Lichtenstein P, Pedersen NL. Prevalence, heritability, and prospective risk factors for anorexia nervosa. Arch Gen Psychiatry. 2006;63:305-12. [11] Hudson JI, Hiripi E, Pope HG Jr., Kessler RC. The prevalence and correlates of eating disorders in the National Comorbidity Survey Replication. Biol Psychiatry. 2007;61:348-58. [12] Makino M, Tsuboi K, Dennerstein L. Prevalence of eating disorders: A comparison of Western and non-Western countries. Med Gen Med. 2004;6:49.
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[13] Keel PK, Klump KL. Are eating disorders culture-bound syndromes? Implications for conceptualizing their etiology. Psychol Bull 2003;129:747-69. [14] Keel PK, Dorer DJ, Eddy KT, Franko D, Charatan DL, Herzog DB. Predictors of mortality in eating disorders. Arch Gen Psychiatry 2003;60:179-83. [15] Steinhausen HC. The outcome of anorexia nervosa in the 20th century. Am J Psychiatry 2002;159:1284-93. [16] Keel PK, Mitchell JE, Miller KB, Davis TL, Crow SJ. Long-term outcome of bulimia nervosa. Arch Gen Psychiatry 1999;56:63-9. [17] Keski-Rahkonen A, Hoek HW, Linna MS, Raevuori A, Sihvola E, Bulik CM, et al. Incidence and outcomes of bulimia nervosa: a nationwide population-based study. Psychol Med 2009:39:823-31 [18] Carter JC, Blackmore E, Sutandar-Pinnock K, Woodside DB. Relapse in anorexia nervosa: A survival analysis. Psychol Med 2004;34:671-9. [19] Halmi KA. Eating disorders in females: genetics, pathophysiology, and treatment. J Pediatr Endocrinol Metab 2002;15(Suppl 5):1379-86. [20] Banks CG. Culture in culture-bound syndrome: The case of anorexia nervosa. Soc Sci Med 1992;34:867-84. [21] Stice E. Review of the evidence for a socio-cultural model of bulimia nervosa and an exploration of the mechanisms of action. Clin Psychol Rev 1994;14:633-61. [22] Kaye WH. Neurobiology of anorexia and bulimia nervosa. Physiol Behav 2008;94:121-35. [23] Nasser M, Katzman MA, Gordon RA, eds. Eating disorders and cultures in transition. London: Brunner-Routledge, 2001. [24] Witztum E, Latzer Y, Stein D. A historical background to current formulations of eating disorders . Chapter 4 in this book. [25] Stein D, Lilenfeld LRR, Plotnicov K, Pollice C, Rao R, Kaye WH. Familial aggregation of eating disorders: results from a controlled family study of bulimia nervosa. Int J Eat Disord 1999;26:211-5. [26] Wade TD, Tiggemann M, Bulik CM, Fairburn CG, Wray NR, Martin NG. Shared temperament risk factors for anorexia nervosa: A twin study. Psychosom Med. 2008;70:239-44. [27] Pinheiro AP, Root T, Bulik CM. The genetics of eating disorders. Chapter 9 in this book. [28] Kaye WH, Frank GK, Bailer UF, Henry SE, Meltzer CC, Price JC, et al. Serotonin alterations in anorexia and bulimia nervosa: new insights from imaging studies. Physiol Behav 2005;85:73-81. [29] Frank GK, Bailer UF, Henry SE, Drevets W, Meltzer CC, Price JC, et al. Increased dopamine D2/D3 receptor binding after recovery from anorexia nervosa measured by positron emission tomography and [(11)C] raclopride. Biol Psychiatry 2005;58:908-12. [30] Klump KL, Strober M, Bulik CM, Thornton L, Johnson C, Devlin B, et al. Personality characteristics of women before and after recovery from an eating disorder. Psychol Med 2004;34:1407-18. [31] Cassin SE, von Ranson KM. Personality and eating disorders: a decade in review. Clin Psychol Rev 2005;25:895-916. [32] Mushatt C. Anorexia nervosa: a psychoanalytic commentary. Int J Psychoanal Psychother 1982-1983;9:257-65. [33] Bruch H. Eating disorders: Obesity, anorexia nervosa and the person within. New York: Basic Books, 1973.
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Introduction
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[34] Strober M, Freeman R, Morrell W. The long term course of severe anorexia nervosa in adolescents: survival analysis of recovery, relapse, and outcome predictors over 10-15 years in prospective study. Int J Eating Disord 1997;22:339-60. [35] Fairburn CG, Marcus MD, Wilson GT: Cognitive-behavioral therapy for binge eating and bulimia nervosa: A comprehensive treatment manual. In: Fairburn CG, Wilson TG. Binge eating: Nature, assessment and treatment. New York: Guilford, 1993:361-404. [36] Fairburn CG, Cooper Z, Shafran R. Cognitive behavior therapy for eating disorders: a “transdiagnostic” theory and treatment. Behav Res Ther 2003;41:509-28. [37] Fairburn CG, Cooper Z, Shafran R. Enhanced cognitive behavior therapy for eating disorders: An overview. In: Fairburn C..Cognitive behavior therapy and eating disorders. New York: Guilford Press, 2008:23-34. [38] Goodsitt A: Eating disorders: A self-psychological perspective. In: Garner DM, Garfinkel PE. Handbook of treatment for eating disorders. New York: Guilford, 1997:208-28. [39] Bachar E. The fear of occupying space. Jerusalem: Hebrew University Magnes Press, 2001. [Hebrew] [40] Minuchin S, Roseman BL, Baker L. Psychosomatic families: Anorexia nervosa in context. Cambridge MA: Harvard University Press, 1978. [41] Boscolo L, Cecchin G, Hoffman L, Penn P. Milan Systemic Family Therapy. New York: Basic Books, 1987. [42] Treasure J. Anorexia nervosa. A survival guide for sufferers and those caring for someone with an eating disorder. Hove: Psychological Press, 1997. [43] Klump KL, Wonderlich S, Lehoux P, Lilenfeld LRR, Bulik CM. Does environment matter? A review of nonshared environment and eating disorders. Int J Eating Disord 2002;3:11835. [44] Langmesser L, Verscheure S. Are eating disorder prevention programs effective? J Athl Train 2009;44:304-5 [45] Levin MP, Smolak L. The case for universal-selective eating disorders prevention programs. Chapter 16 in this book. [46] Levine MP, Smolak L, Hayden H. The relation of socio-cultural factors to eating attitudes and behaviors among middle school girls. J Adol 1994;14:472-91. [47] Canetti L, Bachar E, Gur E, Stein D. The Influence of a primary prevention program on eating-related attitudes of female middle school students. J Adoles 2009;32:275-91. [48] Cororve Fingeret M, Warren CS, Cepeda-Benito A, Gleaves DH. Eating disorder prevention research: a meta-analysis. Eat Disord 2006;14:191-213 [49] Shaw H, Stice E, Becker CB. Preventing eating disorders. Child Adol Psychiat Clin North Am 2009;18:199-207 [50] Neumark-Sztainer D. Parenting teens with a healthy body and a healthy body image. Chapter 18 in this book.
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Section One: Overview
Understanding Eating Disorders: Integrating Culture, Psychology and Biology, edited by Yael Latzer, Nova Science Publishers, Incorporated, 2011.
Copyright © 2011. Nova Science Publishers, Incorporated. All rights reserved. Understanding Eating Disorders: Integrating Culture, Psychology and Biology, edited by Yael Latzer, Nova Science Publishers, Incorporated, 2011.
In: Understanding Eating Disorders Editors: Yael Latzer, Joav Merrick, Daniel Stein
ISBN 978-1-61728-298-0 © 2011 Nova Science Publishers, Inc.
Chapter 1
Why DSM V needs to Consider a Staging Model for Anorexia Nervosa
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Sarah Maguire4, BSc (Hons.), PhD1, Stephen Touyz, BSc, PhD2 , Lois J. Surgenor, MA (Hons), PhD, DipClinPsych3, Hubert Lacey, MD, MPhil, FRCPsych, DipObst4 and Daniel Le Grange, PhD5 Attention to the conceptualization and diagnosis of eating disorders is increasing in intensity as the Diagnostic and Statistical Manual for Mental Disorders, 5th edition (DSM V) approaches. The current diagnostic criteria for each of the eating disorder categories have been criticized and alternate criteria proposed. They have been accused of being unreliable, both too liberal and too restrictive and of failing to reflect clinical reality. The objective of the present chapter is to focus primarily on the diagnostic conceptualization of anorexia nervosa (AN), and will review the use of staging in the medical and psychiatric illnesses as a remedial strategy for current problems besetting the conceptualization of the AN spectrum of illness. The findings of this review suggest that varying levels of severity within the illness category of AN is a concept long appreciated within the scientific community. However, neither a precise definition of severity, nor a subsequent empirical examination of severity in AN, has been previously undertaken. A model to stage the illness according to severity should be introduced in future iterations of the DSM
Correspondence: Sarah Maguire, Centre for Eating and Dieting Disorders, Sydney South West Area Health Service, c/ RPAH Level 2 Building 92, Camperdown NSW 2050, Australia. E-mail: [email protected]. 1 Centre for Eating and Dieting Disorders, Sydney South West Area Health Service, Camperdown, New South Wales, Australia, 2 Psychology Department, University of Sydney, New South Wales, Australia, 3Department of Psychological Medicine, University of Otago at Canterbury, Christchurch, New Zealand, 4 Division of Mental Health, St George's, University of London, London, United Kingdom and 5 Department of Psychiatry and Behavioral Neuroscience, University of Chicago, Chicago, Illinois, United States of America 4
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Introduction In 2003, we stated that “….with the best will in the world, it is difficult not to become disillusioned with the diagnostic system for eating disorders. Although repeatedly revised, diagnostic criteria such as those of the Diagnostic and Statistical Manual for Mental Disorders, 4th edition (DSM IV) or the International Classification of Diseases, 10th edition (ICD 10) are inadequate to describe the patient’s condition” (1). Since then, there has been considerable debate within the field of eating disorders as to what kind of diagnostic system we should embrace in the future (2-4). As can be expected in such a diverse field as ours, there is no consensus as to what approach the DSM V should take. However in 2012, we will all have to live with the realities that the DSM V will provide. At this time it will be simply too late to argue what might have been. Now is the time to express our views as to which diagnostic model we want the American Psychiatric Association to adopt. Joyce (5) has argued cogently that “… for any diagnostic system to be clinically useful, and go beyond description, it must provide an understanding that informs about etiology and/or outcome” (p.851). It is within this framework that this chapter has been written. It will come as little surprise to the reader that although there is a lack of consensus as to what diagnostic system we should endorse, there is a chorus of complaints regarding the inadequacies of the current system. It is no longer sustainable to have between 50-70% of patients, who present for treatment at eating disorder clinics throughout the world, receiving diagnoses of Eating Disorders Not Otherwise Specified (EDNOS) (2,3,6,7). When a preponderance of patients is given a Not Otherwise Specified (NOS) diagnosis, many agree that there is a fundamental problem with the clinical applicability of the diagnostic criteria (8). However, the vexed question is how this should be remedied. Should the ICD criterion of a body mass index (BMI) of 17.5 or less be raised for those patients with anorexia nervosa (AN)? Many would strongly oppose this view as under nutrition has always been a cardinal feature of AN. Should amenorrhea be dropped as a diagnostic criterion? There seems to be little evidence to support its inclusion (9,10) and with so many females using the oral contraceptive pill, it is difficult to ascertain (11). There is even more disillusionment with the diagnostic criteria for bulimia nervosa (BN). One would have thought that there would at least be agreement as to what constitutes a binge, the key feature of this disorder. Sadly, this is not the case as many patients become extremely distressed by relatively small subjective binge episodes and report intense loss of control accompanying these. Furthermore, do we have sufficient scientific evidence to argue that two binge episodes on average per week is sufficient to meet diagnostic criteria for this illness whereas once per week does not (12)? All in all, our current diagnostic system is less clinically helpful than originally envisaged and has clearly outlived its usefulness. However, none of us likes change, and will the American Psychiatric Association take this unique opportunity to radically modify an ailing and almost terminal diagnostic system? We suspect not. The likely outcome is going to be very minor changes which will be more of a band aid nature than the radical surgery required. We believe that the field of eating disorders would be best served if we developed a bold vision for the future. The best way to achieve this would be through the adoption of a two-stage process as previously suggested in the literature (5). This would involve the immediate introduction of more modest changes in the DSM V, followed by more substantial
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Why DSM V needs to Consider a Staging Model for Anorexia Nervosa
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modifications in the DSM VI. This stepped approach would allow longer term planning, especially by researchers whose livelihood is often dependent upon grant funding and a more orderly progression to a new, more meaningful diagnostic system which would provide the field with the direction it so sorely needs. We would like to reiterate that we can no longer defer making a decision as 2012 is almost upon us. Against this background of diagnostic dissatisfaction, this chapter will focus its attention on AN, and specifically argue as to why a staging model of the illness needs to be introduced in future iterations of the DSM. The reason we have decided to focus on AN is that it remains the most serious of all psychiatric illnesses (1). Although rare when compared with major public health problems such as obesity, hypertension or substance abuse, AN is common among serious chronic illness. Its point prevalence for girls between the ages of 15 and 19 years is 0.5%, and above half as much for women aged 20 to 24 years (13,14). In these groups it is 10 times more common than insulin-dependent diabetes mellitus. The life time risk of a woman developing AN is half that of schizophrenia. Its mortality rate on a number of followup studies over 20 years is about 20% (15) which is totally unacceptable for a disease whose onset is usually in adolescence. Many patients develop a severe and unrelenting form of the disease, with a degree of social isolation as great as that of schizophrenia. The burden that this illness places on society is high (16) and its load on hospital services considerable (17-19). We have argued for some time now that not unlike depression, it was time to think about AN in a very different way to our current stereotyping (1). We argued then, as we do now, that our current diagnostic criteria, such as those presented in either DSM IV or ICD 10, are inadequate to describe the patient’s clinical condition. Not unlike neoplasia, AN is a disease that merits staging. In fact, in psychiatry in general there is a growing interest in staging as a diagnostic strategy for DSM-V (20,21). In a recent editorial in the America Journal of Psychiatry, McGorry urged psychiatry to endorse a staging model similar to that used in medicine (22). “Clinical staging is a proven strategy whose value is clear in the treatment of malignancies and many other medical conditions in which the quality of life and survival rely on the earliest possible delivery of effective interventions, yet it has not been explicitly endorsed in psychiatry”(22)
McGorry (22) went on to argue that staging “differs from conventional diagnostic practice in that it defines the progression of an illness in time and where a person lies along this continuum during the course of illness” (p.859). We have now given considerable thought to adopting staging as a model of severity in AN.
Categorical versus Dimensional Models of Illness In modern times AN has been conceptualized for the purposes of diagnosis using a categorical approach. Categorical approaches possess a number of advantages. Categories make for ease of communication between health professionals, patients and other parties. Clear categories aid in research methodology making findings more easily interpretable and
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comparable. At a more fundamental level, categorical reasoning arises naturally from the medical model and appeals to the familiar concept of distinct disease entities (20). However appealing and familiar as a system, the categorical approach to diagnosing mental illnesses also has several limitations. When categories are applied to continuous constructs, information is lost. AN has been purported to exist on a continuum (23,24) and cluster analytic studies have found support for such an assertion, repeatedly reporting two dimensions of illness within the eating disorders – one best described as anorexic-type illnesses and the other as binge-type illnesses (25,26). If anorexic symptoms present on a spectrum, then the validity and merits of a categorical approach are seriously questioned. Further, the application of these flawed diagnostic categories becomes an awkward and confusing endeavor that can provide more experiences of poor fit than it can of good (8). Although they can lack the ease of communication offered by a categorical approach, dimensional approaches to illness conceptualization may have several advantages. For symptoms that present over a range of expression or for syndromes with unclear boundaries, which is arguably the case for AN (2,3,27), dimensions can offer a working paradigm that conveys useful information (20). While we are not aware of any studies that have directly examined the utility of dimensional factor scores compared to categorical diagnoses in predicting clinical course and outcome in AN, studies examining the outcome of EDNOS and AN cases offer some insights in this regard. The limited number of studies that have examined outcome of both EDNOS and AN cases indicate little support for the predictive utility of these two diagnostic categories (6,28,29). Yet abandoning the categorical approach altogether and replacing it with dimensions may be premature and entail its own set of problems. The transdiagnostic approach proposed by Fairburn and colleagues (12,30) which argues to collapse all existing eating disorder categories into one is novel, but presently challenged by the lack of an evidence base to support it (31) along with the obvious risk of lost specificity. Theorists within the field of eating disorders tend to support a synthesis of both ways of thinking, with many advocating a reconceptualistation of AN that still involves some taxonomy in combination with dimensions (23,24). Consistent with this sentiment, clinical staging can be viewed as a middle ground solution between a categorical and dimensional view of illness. The current categorization utilized by the DSM classification system offers for the most part a dichotomous conceptualization of psychiatric disturbance as ill or not-ill. Staging still utilizes imposed, and some might say arbitrary, cut-offs that divide what is arguably a continuous entity into discreet units, but it does so based on the fundamental assumption that there is a progression of disease along a continuum or dimension (22). Some proponents of clinical staging refer to it as a more refined form of diagnosis (32), arguing that it allows an individual to be placed at any point in time along a continuum of illness, defining the extent of illness at that juncture (33). This in turn frames the illness in such a way as to naturally highlight opportunities for early intervention to prevent illness progression, and to match treatments to stage.
The History of Disease Staging Staging refers to the determination or classification of distinct phases or periods in the course of a disease or pathological process; that is, the determination of the specific extent of a
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disease process in an individual person (34). Staging has long been used as a strategy to operationalise illness severity. The earliest attempts at staging were reported in 1748 by Fotherill who published a system for categorizing diphtheria according to severity. His system, which staged diphtheria according to the physical manifestation of the illness, described stage I, characterized by superficial inflammation, through to stage III, characterized by deep ulcers. Although the stages were devised without the benefit of empirical evidence as to their relationship to prognosis, subsequent research utilizing this staging system found that there were in fact corresponding differences in expected outcome dependent upon the stage to which the disease had progressed within the individual. Since then a number of medical illnesses have been successfully staged. The next well-documented attempts at staging were published in 1814 by Boyer, who outlined a staging system for the classification of burns, which is still used extensively today. He described first, second and third degree burns, which could be differentiated according to the depth or thickness of the burn. The staging of a disorder or disease has traditionally resulted in a number of consequent developments, one of which is the development of treatment guidelines for each stage of the illness, and the staging of burns resulted in just such a system. Subsequent to the development of appropriate treatment for each burn stage, differences in outcome and mortality from burns were reported in the literature (35). Perhaps the most widely recognized and well documented staging model is that used for cancer. The TNM System (Tumor, Node, Metastasis) divides cancers into five stages from the least (stage 0) to the most severe (stage IV), based on the anatomical extent of the cancer on three axes; the physical extent of the tumor (T), the involvement at the lymph nodes (N) and distant spread or metastasis (M). The purpose of the TNM classification when developed in the 1980’s was outlined as fourfold (36): a) to select appropriate standard treatments, b) to evaluate the results of new treatments, c) to acquire data in an orderly fashion for statistical analysis of end results, and d) to estimate prognosis. All four goals have been significantly advanced since the TNM system was agreed upon in 1987 (37). The cancer model is continually evolving, with research underway to incorporate new indicators of prognosis such as genetic markers and specific treatment factors (38). It is also recognized that the maintenance of a standardized system for staging, according to the anatomic extent of the illness, in preserving the TNM fundamentals, is necessary for ongoing research in the field (39). Since its development, the staging system for cancer has been demonstrated time and time again to be effective in matching persons to the best treatment, and broadly in predicting prognosis (40-42).
Staging of Psychiatric Illnesses Several mental illnesses have also been staged, although these have a shorter history and are usually rudimentary in nature. Dementia, first staged in the previous century, is an illness whose progression follows a fairly uniform course, which makes it suitable for staging. Alcohol use has been staged according to severity, with different prognoses indicated by the respective stage of illness. Schizophrenia uses a course-like staging separating illness groups into acute, remitting or chronic stages. However, thus far, comprehensive staging models such as those used for cancer and burns, have not been applied in mental illnesses.
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Fava and Kellner (43) were the first to describe the potential utility of comprehensive staging models in the diagnosis mental illnesses. In 1993, they published a paper entitled ‘Staging: a neglected dimension in psychiatric classification’. It was their contention that in psychiatry, as in the medical realm, there is often a clinical need to rate the seriousness, extent and characteristics of an illness, and that staging as used in oncology and other physical illnesses does exactly this. They suggested that the neglect of the staging concept in psychiatry reflects the field’s reliance on cross-sectional descriptions of state instead of longitudinal study of illness (p. 226). Their article outlined staging systems for schizophrenia, unipolar depression, bipolar disorder and panic disorder. Their work, however, and the notion of staging in general, was further neglected until very recently. In this century, the pioneering thinking of Fava and Kellner has been picked up by the group led by McGorry - arguably the single biggest proponent of a staging model for the psychiatric disorders. McGorry (22) has issued a comprehensive critique of psychiatric diagnosis, calling it at best ‘syndromal’ and arguing that both its clinical utility and predictive validity are questionable (44, page 616). As a clinical tool to guide treatment choice and to better understand prognosis, McGorry argues that staging has the potential to provide a conceptual framework to incorporate the broad social, biological and personal risk and protective factors that influence movement across stages. Staging may further improve our understanding as to which interventions delivered at which stage can alter best the course of illness progression (22, page 859). His group have in the last three years published papers proposing staging models for psychosis (44), mood disorders in general (32), and then individually for bipolar disorder (21) and unipolar depression (33). McGorry argues that the staging model is broadly applicable to a range of mental illnesses and suggests it is a suitable classification strategy for ‘any potentially severe illness [that] may progress if untreated’ (22, page 859). This statement could easily apply to AN.
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Staging in Anorexia Nervosa It is not widely known that even the earliest descriptions of AN made reference to the concept of stages of severity within the illness. Lasègue (45), who along with Gull (46) is credited with providing the first published accounts of AN, describes a gradual descent into the illness, distinguishing three distinct ‘phases’ in its progression. The first, he wrote, is marked by an ‘uneasiness and fullness’ after eating, with a consequent reduction in food intake and/or the beginning of food refusal. The second is marked by severe restriction, increased activity levels and an ‘intellectual perversion’ resulting in a complete denial of the illness, before finally ‘the disease enters upon its third stage’, involving extreme emaciation, laborious exercise and a ‘general debility’. Investigators and observers since that time have continued to allude to discreet stages within AN. For example, some have referred to an acute stage versus a re-feeding stage, or a chronic stage versus a recovered stage of the illness (47). Others have described the illness in terms of a progression through stages (48). The ‘chronic’ stage of AN is the one most often referred to in the literature. A number of studies have investigated the various physical and psychological concomitants of what researchers describe as ‘chronic AN’ (49-51). Generally presumed to be the worst manifestation of the disorder and with the poorest prognosis, the
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criteria for classification within the ‘chronic stage’, or any other stage for that matter, have however not been well investigated. Consequently, many investigators utilize an illness duration of greater than 5 - 7 years as a marker to denote chronicity (52). A different approach to staging AN does not make assumptions about severity, but is rather involved with the course of the illness (53-55). Similar to the course-like staging utilized in schizophrenia, this strategy involves the division of AN patients into the following categories: ill/episode; partial remission/recovery; sustained recovery; and relapse, based on the extent to which persons in a specific stage meet the core diagnostic criteria of AN. While helpful, course-like stages are often somewhat self-evident labels of the diagnostic status of the illness. Further, other than the stages of ill and not ill (episode and remission/recovery), Kordy et al (55) have been unable to demonstrate stability or predictive utility of the other stages. Course-like staging may be understood as a longitudinal examination of the illness, whereas severity-based staging is one that focuses on illness extent. That is, which symptoms in AN, at which degree of intensity, result in which outcome. While the concept of stages of severity of illness have been alluded to throughout the literature, there have been no empirical studies investigating discreet stages of severity within AN, nor how they might be measured or what they might predict. Observed similarities between chronic AN and chronic schizophrenia (56) suggest that a similar course-like staging approach as that earlier described may be useful in AN. It has been observed that AN in its chronic form can present with similar negative symptoms that become pronounced in chronic schizophrenia, for example, blunted affect, social withdrawal and odd ideas. However, the relationship between positive and negative symptoms used in schizophrenia to delineate the chronic stage is not as clear in AN. Even in its chronic form the ‘positive’ symptoms of the illness – e.g., drive for thinness or body image disturbance - can be acutely present, and it is common for persons with chronic AN to continue to be highfunctioning and to lack most or all of these so-called negative symptoms. The existing staging literature reveals several themes of relevance to the field of eating disorders. When prognosis is uniformly poor, staging is regarded as unhelpful (37). When outcome is highly varied, as is the case for AN, then the examination of disease factors that may affect prognosis becomes important. In general, staging systems have emerged in response to a clinical need for further classification, rather than any empirical evidence of inherent stages within the illness category. The staging of a disease can result in a renaissance in treatment development and more effective treatment delivery with consequent improvements in disease outcome and the development of treatment guidelines for each stage of the illness (57,58). While in some cases staging emerges from an observation that outcome or prognosis may be poorer depending upon the ‘extent’ of the illness, such as in the case of cancer, most of the empirical support for such differences in prognosis have been a direct result of, rather than a catalyst for, the development of stages for an illness. Prognostic indicators may be a desired result of staging; however the primary purpose of staging, at least in medical disorders, is to guide treatment selection and case management (38,39). With the exception perhaps of the diagnostic criteria for AN, few subjects receive as much attention in the literature; this is likely related to the dearth of effective treatments for this illness and the need for re-invigoration in this area (59-61). The inter-individual differences within AN, and the lack of a meaningful way to classify and examine its outcome, have been identified as potential barriers for the development of effective treatment.
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Collectively, these arguments emphasize the importance of a thorough examination of the spectrum of illness in AN and possible categories therein. One could argue that the staging of AN is not necessarily such a novel idea (62). Most clinicians would subsume milder “subthreshold” cases of AN within the EDNOS diagnostic category, providing a sort of unofficial staging although across two diagnostic groups. However, doing so results in EDNOS becoming such a broad and heterogeneous category that it severely limits its usefulness as a diagnostic entity (59). EDNOS is further criticized in that it does not necessarily allow for precise case identification or for the development of appropriate treatments. Nevertheless, there is a decided advantage in adopting a staging model of the variety proposed here, in that it allows for all presentations of AN to be subsumed within the same diagnostic category, but with the delineation of subgroups based upon symptomatic and prognostic factors. Further, similar to other illnesses, staging has been an approach applied to understanding motivation for change in AN. Despite an enduring centrality in clinical accounts of the disorder, it is only in the last decade that readiness or motivation for to change has become a focus of theoretical and empirical investigation (52). This growing body of work may provide important insights for future illness staging research. Intended to describe the process of intentional change, the Stages of Change Model (63) is particularly pertinent to disorders in which motivational deficits feature prominently. This is very relevant to disorders such as AN since it recognizes even the earliest stages of the change process, including those individuals who are not yet actively working to change (52). The stages of precontemplation through to action and relapse have been successfully mapped to AN and instruments such as the Anorexia Nervosa Stages of Change Questionnaire (ANSOCQ) have been developed to assess preparedness for change (64). Unfortunately, this is not the full story. Although a useful psychological strategy to adopt, one needs to keep in mind that an individual’s stage of change could only be regarded as one marker of illness presentation, existing within an array of disease presentations (62). On the one hand, it is quite possible to have a patient with AN who is very desirous of change, but at the same time is at a very severe medical risk as a consequence of the illness. On the other hand, a patient could be in partial remission, yet be adamant about having absolutely no intention of reaching a desirable goal weight. These two cases are likely to have different prognostic outcomes. Because of the above, a model of illness staging needs to take not only the motivational stance of the patient into consideration but to encompass psychological, behavioral and physical symptoms as well, in order to arrive at a stage that enables prognostic utility (62). Although we make a strong argument for the inclusion of a staging model of AN in the DSM V, this is not without potential downside. On one hand, it is possible that a staging model may over-pathologise an already stigmatized psychiatric disorder. Furthermore, should such a staging model be adopted, it is possible that patients at either end of the spectrum may be disadvantaged. Those with a subthreshold AN or “Stage 1”, whatever that implies, could be denied the same access to treatment as those who are “Stage 4”, who might be regarded, for example, as too difficult to treat. Such considerations would need to be addressed to ensure that the adoption of a staging model improves both patient care and outcome, with limited opportunity for misuse.
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Conclusions AN is not a new illness. It has been first described in the literature in 1873, but there is clear evidence of its existence well before that time. It has been the subject of empirical investigation since the 1950’s, yet we are no closer to a full understanding of the etiology or prognosis of the disorder. The development of an effective treatment continues to elude us. A new paradigm for thinking about AN diagnoses is highly required, and although considered controversial by some, the resultant debate this may generate could be fruitful. As we have pointed out earlier, there is a dearth of research addressing the diagnostic conceptualization of AN to arrive at a more satisfactory and helpful sub-clarification that helps us to better understand the disorder (62). We believe that apart from the important prognostic considerations, the development of a functional staging system, based on symptom severity, is as necessary for our field of eating disorders as it has been for cancer. Despite all the progress we have made over recent years, AN remains a very serious illness with significant medical morbidity, and if left untreated can lead to permanent incapacity. Such morbidity is related to the “severity” of presentation on such markers as body mass index (BMI), eating, and purging behaviors. The introduction of staging in other fields of medicine has led to improved case management and more appropriate treatment recommendations. Such an argument can easily be made for AN. We are of the opinion that the introduction of a functional staging system for AN would not only ease the communication between treatment settings, but would also improve the specificity and comparability of research findings. To this end, we have developed a staging instrument that separates AN spectrum into subcategories based on symptomatic severity, i.e., the clinician administered Staging Instrument for Anorexia Nervosa (CASIAN) (65). Validation and reliability studies have been undertaken to demonstrate the utility and predictive validity of the CASIAN, and these await publication (66). The time for endless complaints regarding our current diagnostic system for eating disorders is at an end. With the advent of the DSM V, a unique opportunity has expressed itself to ensure that we arrive at a classificatory system that addresses many of the limitations inherent in the current one. As far as AN is concerned, we are of the firm opinion that a functional staging system not unlike the one endorsed by the cancer lobby, is a way of the future. To this end we have developed the CASIAN which will allow clinicians and researchers alike to stage AN. We believe that this will not only allow for earlier detection and treatment of the disorder, but substantially increase the specificity and comparability of research findings as well. Those invested with the task of producing the diagnostic system for the DSM V have an awesome responsibility. We wish them well in their endeavor and if this chapter stimulates further debate to ultimately improve outcome in AN, then it has all been worthwhile.
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[44] McGorry PD, Hickie IB, Yung AR, Pantelis C, Jackson HJ. Clinical staging of psychiatric disorders: a heuristic framework for choosing earlier, safer and more effective interventions. Aust NZ J Psychiatry 2006;40:616-22. [45] Lasegue CH. De l'anorexie hysterique. Translated as: On hysterical anorexia, 1873. In: Kaufman M, Herman M. Evolution of a psychosomatic concept: anorexia nervosa. New York: International Universities Press, 1964;141-455. [46] Gull WW. Anorexia nervosa (apepsia hysterica). BMJ 1873;2:527-8. [47] Halmi KA. Anorexia nervosa and bulimia. Annu Rev Med 1987;38:373-80. [48] Klein DA, Walsh BT. Eating disorders: clinical features and pathophysiology. Physiol Behav 2004;81:359-74. [49] Mehler PS. Diagnosis and care of patients with anorexia nervosa in primary care settings. Ann Intern Med 2001;134:1048-59. [50] Melanson EL, Donahoo WT, Krantz MJ, Poirier P, Mehler PS. Resting and ambulatory heart rate variability in chronic anorexia nervosa. Am J Cardiol 2004;94:1217-20. [51] Krantz MJ, Donahoo WT, Melanson EL, Mehler PS. QT interval dispersion and resting metabolic rate in chronic anorexia nervosa. Int J Eat Disord 2005;37:166-70. [52] Touyz S, Thornton C, Rieger E, George L, Beumont P. The incorporation of the stage of change model in the day hospital treatment of patients with anorexia nervosa. Eur Child Adolesc Psychiatry 2003;12 Suppl 1:I65-71. [53] Strober M, Freeman R, Morrell W. The long-term course of severe anorexia nervosa in adolescents: survival analysis of recovery, relapse, and outcome predictors over 10-15 years in a prospective study. Int J Eat Disord 1997;22:339-60. [54] Herzog DB, Dorer DJ, Keel PK, Selwyn, SE, Ekeblad ER, Flores AT. Recovery and relapse in anorexia and bulimia nervosa: a 7.5-year follow-up study. J Am Acad Child Adolesc Psychiatry 1999;38:829-37. [55] Kordy H, Kramer B, Palmer RL, Papezova H, Pellet J, Richard M, et al. Remission, recovery, relapse, and recurrence in eating disorders: conceptualization and illustration of a validation strategy. J Clin Psychol 2002;58:833-46. [56] Brzozowska A, Wolanczyk T, Komender J. Schizophrenia, schizophrenia-like disorders and delusional disorders in patients with anorexia nervosa: literature review and report of 3 cases. Psychiatr Pol 1998;32:265-74. [57] Mackillop WJ, O'Sullivan B, Gospodarowicz M. The role of cancer staging in evidencebased medicine. Cancer Prev Control 1998;2:269-77. [58] National Comprehensive Cancer Networks. NCNN Clinical Practice Guidelines in Oncology. 2007 [available from: hppt://www.nccn.org]. [59] Fairburn CG. Evidence-based treatment of anorexia nervosa. Int J Eat Disord 2005;37 Suppl:S26-30; discussion S41-2. [60] Hay P, Bacaltchuk J, Claudino A, Ben-Tovim D, Yong PY. Individual psychotherapy in the outpatient treatment of adults with anorexia nervosa. Cochrane Database Syst Rev 2003:CD003909. [61] Le Grange D, Lock J. The dearth of psychological treatment studies for anorexia nervosa. Int J Eat Disord 2005;37:79-91. [62] Maguire S, Le Grange D, Surgenor LJ, Marks P, Lacey H, Touyz S. Staging anorexia nervosa: conceptualizing illness severity. Early Interv Psychiatry 2008; 2:3-10. [63] Prochaska JO, Diclemente CC. Trans-theoretical therapy - toward a more integrative model of change. Psychother Theory Res Pract 1982;19:276-88.
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[64] Rieger E, Touyz SW, Beumont PJV. The anorexia nervosa stages of change questionnaire (ANSOCQ): information regarding its psychometric properties. Int J Eat Disord 2002;32:24–38. [65] Maguire S, Le Grange D, Lacey H, Surgenor LJ, Touyz S. Clinician administered staging instrument for anorexia nervosa. Eating Disorder Research Society Meeting 2005, Toronto, Canada. [66] Maguire S. Unpublished PhD dissertation. Sydney: Univ Sydney, 2009.
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Copyright © 2011. Nova Science Publishers, Incorporated. All rights reserved. Understanding Eating Disorders: Integrating Culture, Psychology and Biology, edited by Yael Latzer, Nova Science Publishers, Incorporated, 2011.
In: Understanding Eating Disorders Editors: Yael Latzer, Joav Merrick, Daniel Stein
ISBN 978-1-61728-298-0 © 2011 Nova Science Publishers, Inc.
Chapter 2
Night Eating Syndrome
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Yael Latzer5, DSc1,2, Kelly C Allison, PhD3, Orna Tzischinsky, DSc4,5 and Piergiuseppe Vinai, MD6 Night eating syndrome (NES) was identified for the first time in the 1950s, but considerable debate and ambiguity still exist regarding its required diagnostic criteria and whether NES should be considered an eating and or a sleep disorder. We review the various diagnostic criteria and different terminologies used for the description of night eating over the years, relating specifically to similarities and discrepancies among NES, nocturnal eating and drinking syndrome (NEDS), and sleep related eating disorder (SRED). We then examine evidence within three different patient populations, namely NES among obese individuals, in patients with additional daytime binge eating disorder or bulimia nervosa, and NES presenting as the primary complaint, to establish the core criteria for NES. We conclude that evening hyperphagia and nocturnal food ingestion should be considered the core diagnostic criteria for NES. We further identify important areas of future research, including the role of distress, the improvement of our understanding of the relationship between evening and daytime eating disorders, and the need to establish collaborative investigations of eating and sleep researchers. The new proposed criteria for diagnosis of the night eating syndrome (NES) are presented.
1 Eating
Disorders Clinic, Psychiatric Division, Rambam Medical Center, Haifa, Israel, Social Welfare and Social Sciences, University of Haifa, Haifa, Israel, 3 Center for Weight and Eating Disorders, School of Medicine, University of Pennsylvania, Philadelphia, United States of America, 4 Emek Yezreel College, Emek Yezreel, Israel, 5 Sleep Laboratory, Faculty of Medicine, Technion-Israel Institutee of Technology, Haifa, Israel. Correspondence: Yael Latzer, DSc, Eating Disorders Clinic Rambam Medical Center, Haifa, Israel University of Haifa, Faculty of Social Welfare and Health Sciences, Mount Carmel, Haifa, 31905 Israel. E-mail: [email protected]. 6 Studi Cognitivi Post-graduate Cognitive Psychotherapy School Research Group, Milan, Italy 2 Faculty of
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Introduction The inclusion of any disturbance in a standardized classification such as the Diagnostic Statistical Manual (DSM) of Psychiatric Disorders is predicated on the disorder having clear diagnostic criteria that are replicable and delineate it from other disorders (1). This has always been a problem in the case of night eating syndrome (NES). Since its first description in 1955 by Stunkard, Grace and Wolff (2), 19 definitions of NES have been identified (3). Moreover, across the years other syndromes have included, and/or still include nocturnal ingestions (i.e., waking up during the sleep period for the purpose of eating) among their symptoms. Because of the overlap of NES with other disorders and the use of multiple criteria sets, we will first provide a historical review to clarify these different diagnostic criteria. Then, using three diverse participant pools to illustrate the problem, we will propose new directions for research towards a unified definition of NES.
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A Historical Review Originally, the core characteristics for NES included insomnia, morning anorexia, evening hyperphagia (25% of daily food intake after 7 pm), lower mood during the evening hours and emotional distress (2). In 1986, Kuldau and Rand (4) suggested modifying the diagnostic criteria in the following way: feeling tense, upset or anxious as bedtime nears, having difficulties going to sleep, evening hyperphagia without enjoyment, and morning anorexia. In 1996 Stunkard and his colleagues (5) further refined the diagnostic criteria for NES, requiring three symptoms: morning anorexia, insomnia, and 50% of daily calories consumed after 7 pm. Emotional distress, a core characteristic of Stunkard's original definition in 1955, was not a diagnostic requirement until Rand, Macgregor and Stunkard (6) recommended it again as part of the diagnostic characteristics for their 1997 study. The presence of night time awakenings with nocturnal ingestions was not required until 1999, when Birketvedt et al (7) added this symptom, but this group did not require the inclusion of distress. Since 1999, when nocturnal ingestions were added to the proposed criteria for NES, not all researchers have included this behavior in their diagnostic sets, or even assessed it descriptively (8,9). Additionally, the presence of insomnia has been cited as a criterion for NES since its inception, but the relation of NES to other sleep disorders, for example night eating associated with disordered sleep and wake patterns (10), has not been clear. Self-reported co-morbidities in NES have been moderately high (11), but sleep studies have not shown evidence of an overlap between other sleep disorders and NES (12). Despite the proliferation of diagnostic criteria since its original description, only nine reports were published on NES between 1955 and 1991, seven of which were case reports (13). Until the 1990s, night eating appeared to be nothing more than a curiosity. Since the beginning of the 1990s, interest in this syndrome rose again, and currently a Medline searched identified 75 articles on NES. However, the diagnostic discrepancies have not yet been resolved. One key question involves the cut-off time for the diagnosis of evening hyperphagia. Some reports have used 7 pm (5), 8 pm (7), or after dinner (14,15). Experts from European countries rightfully noted that the hour of evening meal differs crossculturally. Adami (16) suggested modifying the diagnostic criteria as follows: no (or a little)
Understanding Eating Disorders: Integrating Culture, Psychology and Biology, edited by Yael Latzer, Nova Science Publishers, Incorporated, 2011.
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food for breakfast, sleep disturbances, usual consumption of some food just before going to sleep, or waking up during sleep to eat. Accordingly, a first step toward resolving the question of whether NES should be recognized as a distinct eating disorder involves developing a uniform definition of the syndrome (3). In the next sections we relate night eating to several different diagnostic descriptions associated with it, as they have been described in the literature over the years.
Night Eating Drinking Syndrome
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A disorder termed night eating and drinking syndrome (NEDS) was included among the sleep disorders in 1990. NEDS was defined by the American Sleep Disorders Association as “frequent and recurrent awakenings to eat and normal sleep onset following ingestion of the desired food” (17). This disorder is no longer included in the 2005 ICSD (18). This definition did not indicate a specified amount of food required for consumption to meet NEDS diagnostic criteria, which only further increased the ambiguity in the diagnostic process. The NEDS definition (often referred to as nocturnal eating syndrome) was used in several studies (19-21). In some articles, the terms night eating and nocturnal eating are used synonymously (13,21,22), suggesting that there is little difference in the occurrence of the two syndromes. Indeed, in the ICSD, night eating was synonymous with, and included as a key word to, NEDS (17). In 2001 Cerú-Björk, Andersson and Rössner (23) defined nocturnal eating as eating at night during the sleep period and night eating as eating excessively before bedtime. As “nocturnal” and “night” are similar terms in the English language, this nuanced differentiation seemed confusing. To make this distinction clearer, Allison et al (14,24) subsequently termed the behavior of eating during the sleep period as “nocturnal ingestions” and the behavior of overeating after the evening meal, “evening hyperphagia”.
Sleep Related Eating Disorder In 1994, Schenck and Mahowald (13) first described a syndrome characterized by nocturnal ingestions with little or no awareness or later recollection of the event, and termed it sleep related eating disorder (SRED). During the night, subjects sometimes ate non-edible objects or injured themselves trying to cut food. The main difference between SRED and NEDS was that NEDS patients, like NES patients, were awake and aware of what they ate, whereas SRED was defined as a parasomnia. In the current version of the SRED diagnostic criteria (18), the main diagnostic criterion is “Recurrent episodes of involuntary eating and drinking occurring during the main sleep period” (ICED, p.174). Additionally, only one or more of 6 other criteria must be present, including consumption of strange items, insomnia, sleep-related injury, occurrence of dangerous behaviours in the search for food, morning anorexia, and adverse health consequences related to nocturnal eating. Thus, lack of awareness of eating is not listed currently as a required criterion, whereas insomnia and morning anorexia are. These changes blur even more the already unclear diagnostic lines between SRED and NES. Moreover, there
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is no mention of the relationship between evening hyperphagia and SRED. Recently, eating and sleep researchers have convened to debate this issue (First International Night Eating Symposium, April 26, 2008, Minneapolis, MN, USA), resulting in some clarification. The main diagnostic difference between the two disorders is the quality of the experience of eating during the night. For SRED, the sufferer is either unaware of the food intake, or they are eating non-food or unusual food items. In NES, typical food items are ingested, and the sufferer is aware and has recall for the behavior. In 1999, Winkelman and associates (25) were among the first to attempt to identify and distinguish between SRED and “simple nocturnal eating” (defined as eating during the night while aware), among eating disorder (ED) patients, depressed patients, and a non-psychiatric population. They found that simple nocturnal eating with awareness was more common than often thought (9.4%), and more common than sleep-related eating (4.7%) in the overall sample. Rates were the highest among those who had pre-existing daytime ED, and sleep disorders were often associated with sleep-related EDs (25). Sleep disorders have been hypothesized to play a role in SRED, but not in simple nocturnal eating with awareness, though they have not been used for diagnostic purposes (13, 22, 26-29).
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Night Eating Syndrome and Obesity Does the proliferation of diagnostic definitions of individuals who eat at night underscore the presence of different kinds of night eaters, or is it only an artifact? In 2006, de Zwaan and colleagues compared the psychological and behavioural characteristics of self-described night eaters diagnosed with either Stunkard’s 1955 criteria (2) or Birketvedt’s 1999 (7) criteria. In a sample of 106 subjects, 31 (29%) met Stunkard’s 1955 criteria and 14 (13%) those of Birketvedt; only 8 participants met both sets of criteria, whereas 50% met neither. The authors found no differences between participants meeting full diagnostic criteria (either 1955 or 1999) on any of the variables assessed such as age, BMI, the presence of diabetes, antidepressant or sleeping pill usage, psychiatric co-morbidity, comorbid sleep disorders, or a lifetime history of an ED. One of the authors of the present review, Vinai and his colleagues (30) at the Studi Cognitivi research group in Milan, Italy, investigated whether using different diagnostic criteria in a sample of obese individuals seeking weight loss therapy would identify different groups of night eaters and whether these different groups would show different psychopathological traits. A consecutive series of 202 obese persons seeking bariatric surgery were tested during a 6 month period. Their mean age was 48.5 years (15-77), 80% were female, and their mean BMI was 43.03 kg/m2 (31.24 -70.86). Seventy patients (35%) were diagnosed with binge eating disorder (BED). The authors then sought to identify the presence of NES in their sample according to four sets of criteria: Stunkard et al, 1955 (2) and 1996 criteria (7), the diagnostic criteria for NEDS (ICSD 1990), and having a score of 25 or greater on the night eating questionnaire (NEQ) (31). The NEQ, currently considered the only validated instrument for screening NES, was created as a screening tool to allow for diagnostic uniformity of the disorder. It has a four-
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factor structure covering behavioral and psychological aspects of: 1) nocturnal ingestions, 2) evening hyperphagia, 3) morning anorexia and percent of total daily food intake consumed after dinner, and 4) mood and sleep disturbances. These factors seem to represent core features of NES, as they account for 67.3% of the variance in the definition of NES with the NEQ. Cronbach's alpha for the total NEQ scale is .70. The main differences between the four diagnostic criteria tested were: • •
Presence of morning anorexia (not required in the NEDS/ICSD classification). The proportion of food required for evening hyperphagia i.e., no amount specified (ICSD 1990), 25% (2), and 50% (5).
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The results of this study show that 32, 19, 23, and 29 of the 202 patients were identified as having NES with the 1955 and 1996 criteria of Stunkard, the ICSD/ NEDS and the NEQ (31) criteria, respectively. The overlap between the different diagnostic criteria is described in figure 1. Remarkably, only one subject met the diagnostic criteria of all the four classifications. The four groups of patients were additionally tested for anxiety (Self Rating Anxiety Scale, 32), worry (Penn State Worry Questionnaire, 33), mood (Self Rating Depression Scale, 34), ED symptoms (Eating Disorder Inventory, 35), and sleep disorders (Sleep Disturbance Questionnaire, 36, and the Insomnia Severity Index, 37). The only between-group difference found was that patients scoring more than 25 on the NEQ and those meeting the ICSD 1990 criteria had significantly higher scores on the mental anxiety subscale of the sleep disturbance questionnaire.
Figure 1. Overlap between the groups of NES patients following different diagnostic criteria.
These findings led Vinai and colleagues to conclude that the NEQ represents a useful screening instrument for NES, and that insomnia and evening hyperphagia (appearing in all classifications), as well as morning anorexia (appearing in all classifications except the
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NEDS/ICDS) should be included in the classification of NES. In other words, the original diagnostic criteria (2) modified following the suggestions of Adami (16) are adequate to screen the majority of NES patients. Based on this work, Vinai et al (30) also suggested that evening hyperphagia before bedtime and nocturnal eating are sustained by a dysfunctional belief, namely that good sleep is dependent on eating in the late evening or during the night. To test this hypothesis, the authors asked the participants if they thought it was impossible to fall asleep without eating. For this purpose, the authors examined 202 obese patients: 32 patients were diagnosed with NES; 70 patients were diagnosed with BED, of whom 16 were also affected by NES. Sixtynine percent of NES patients and 63% of the 16 patients with a double diagnosis of NES and BED agreed with this statement in comparison to none of the remaining 54 BED patients and only 4.8.% of the remaining 116 non-BED obese patients. This finding lends evidence to the idea that, among patients with both NES and BED, the dysfunctional conviction, “If I do not eat, I cannot sleep,” is a common pathway to night eating. By contrast, patients affected by BED with no NES and obese subjects not affected by any ED seem to follow different pathways toward overeating.
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Night Eating among Persons with Eating Disorder Several anecdotal cases have confirmed the existence of night or nocturnal eating syndromes as distinct from daytime EDs (19,27,38). To our knowledge, only one study has focused on night eating among overweight BED patients (19), and only a two case studies and one small survey study have described any form of night or nocturnal eating syndromes among bulimia nervosa (BN) patients (27,38,39). NES is a clinical syndrome comprising difficulties with both eating and sleeping. Eating disturbances, particularly binge-eating, either in the form of BN or BED has been hypothesized to play a role in NES. Similar to NES with no daytime EDs, nocturnal ingestions among BED and BN patients consist of eating episodes after sleep onset, although the amount of food consumed during these episodes has not been described well enough to know if they meet criteria for a binge. In non-eating disorder NES samples, the size of nocturnal ingestions is not objectively large enough to be considered a binge episode (7,14). Recently, Tzischinsky and Latzer (40) examined BN and BED patients with respect to their sleep-wake cycles and associated characteristics of nocturnal ingestions. The study was conducted over a three year period and included twelve BED and ten BN patients suffering also from nocturnal ingestions. All patients were monitored by a mini-Actigraph (objective measurement of the sleep-wake cycle) for one week, completed the Mini-Sleep Questionnaire (MSQ) (41), and provided demographic and relevant clinical data (40). Sixteen percent of all BED patients and 9% of all BN patients studied during the three year period had evidence of nocturnal ingestions. Acute subjective sleeping disorders (MSQ Total Score) were shown in both groups. Significant differences between the 12 BED and 10 BN patients with nocturnal ingestions were found for two MSQ factors, with the BED group reporting significantly more snoring complaints and the BN group reporting more headaches the morning after awakenings. Both groups showed low sleep efficiency, but normal sleep duration, relative to an age and BMI matched control group (10,40,42). The authors suggest
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that the reports of snoring by those with BED can be explained by this group’s higher BMI, and the report of more headaches among the BN group may be the result of their compensatory purging behaviors prior to their sleep onset. No significant differences were shown between the BN and BED patients with nocturnal ingestions on the objective Actigraph results (40). The mean number of Actigraph-monitored nocturnal ingestions per night was 3.0 ± 2.2 (range 0-6) in the BN group and 3.9 ± 2.2 (range 1-7) in the BED group. The duration of each nocturnal ingestion was between 5-10 minutes and occurred after falling asleep. Twenty of the 22 subjects reported being fully awake during their nocturnal ingestions and eating compulsively shortly after awakening due to an urgent, abnormal craving unaccompanied by hunger pangs. Only two patients reported that they were unaware of their nocturnal ingestions (evidenced by a messy kitchen in the morning and confirmed with actigraphy). The patients’ clinical reports indicated that the main promoting factors related to the onset of nocturnal eating included such traumatic life events as divorce, car accident, and illness or death in the family. In 45% (n = 10) of the patients, of whom half had BED and the other half BN, sexual abuse was reported during childhood and/or adolescence; 9% (n = 2) reported the occurrence of physical abuse during some period of their life. Clinical assessment according to DSM-IV criteria revealed considerable psychiatric comorbidity, mainly depression and anxiety, in 80% of the BN patients and 67% of the BED patients. Furthermore, the results have indicated that traumatic life events, including sexual abuse, as well as the appearance of psychiatric comorbidity, have coincided closely with the onset of nocturnal ingestions among both the BED and BN groups. These results support those of previous studies, although these included both NEDS and SRED patients (13,20). Nevertheless, it is still unclear whether psychiatric comorbidity, sexual abuse and traumatic life events are more prevalent among ED patients with nocturnal ingestions than among patients with only daytime EDs.
Night eating among Individuials with NES Allison and colleagues (43) sought to assess the eating–related and non-eating related characteristics among individuals for whom NES was their primary complaint. To this end, they compared persons with only evening hyperphagia (EH; consumption of >25% of daily intake after dinner), only nocturnal ingestions (NI; > 3 per week), or both disturbances (EH/NI) on a broad range of behavioral and psychosocial measures. One hundred forty-eight participants completed semi-structured interviews and 10-day food, mood, and sleep diaries to assess symptoms of NES (43). Participants completed demographic information, the Structured Clinical Interview for the DSM (SCID; 44), the eating disorder examination (45), and a battery of eating, mood, and stress surveys. Of the 148 night eaters: 25 (17%) had only EH, 24 (16%) had only NI, and 99 (67%) had both features (EH/NI). All groups were similar across demographic variables, except for BMI, which was lower in the EH/NI group (31.5 kg/m2) than the EH group (35.7 kg/m2); the NI group did not differ from the other groups (43). As would be expected based on definition of the groups, the NI and EH/NI reported more nocturnal ingestions than the EH group, and
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the EH/NI and EH groups reported a higher percentage of intake after the evening meal. All participants who had nocturnal ingestions were aware of their occurrence. Survival analyses showed that the median time to consumption of 75% of daily calories for the NI group was earlier (8:00 pm) than for the other two groups (10:00 pm; NI only vs. EH only, p11 yrs) reported, clinician rated webbased questionnaire
Linked to DSM IV diagnostic criteria, used for purpose of diagnosis
EDE-Q
BSQ
Normative data available for 12-14yrs and for 14 yrs+
Garner 1991 Eklund et al 2005 Fairburn and Beglin 1994
12-18 yrs
Geller and Drab 1999
Validated on adolescents, mean age 15
Gusella et al 2003
Age 7-17
Moya et al. 2005 House et al 2008
.action?docID=3017896.
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Diagnostic issues III: The Appropriateness of the Current Diagnostic Nomenclature Increasingly there is debate about the appropriateness, utility and validity of the current diagnostic systems of DSM-IV and ICD-10, based as they are, largely upon clinical opinion and expert consensus rather than empirical research (40). Concerns has been raised about each of the individual diagnostic criteria, the validity of distinguishing between subtypes of anorexia or bulimia nervosa , and in some cases even raising concerns about whether anorexia and bulimia nervosa are valid diagnoses (41). These criticisms have included debate around the potential cultural bias present in criteria such as ‘fear of weight gain’ (42), the unreliability of the marker of amenorrhoea (43), the difficulty in operationalising a number of the criteria (such as the size of a binge), and the lack of evidence to support having the frequency of bulimic symptoms as a measure of severity (44). These issues have been increasingly topical in light of the upcoming revisions currently being discussed for the DSMV, and a number of alternative classification systems have been proposed based on advanced statistical models or alternative conceptualisations of the core features of the eating disorders (45,46). When considering the eating disorders in children and adolescents, the criticisms of the current diagnostic systems are further compounded by the fact the criteria were developed in relation to an adult population, without reference to the younger age group, are not developmentally sensitive and fail to describe to majority of the clinically significant eating disorders that occur in children (16,47). Ongoing debate about the boundaries within the eating disorder diagnoses has detracted somewhat from the debate around what is and what is not an eating disorder. Cultural as well as developmental differences in presentation and clinical features have been well described, but uncertainty remains about how best to categorise clinical presentations that do not fit within anorexia, bulimia nervosa or EDNOS. In clinical practice it is not uncommon to see children and adolescents present with difficulties where food refusal is the central symptom and which can be understood within a psychological formulation, but which appear to be quite distinct qualitatively from either anorexia or bulimia nervosa or their subsyndromes. These ‘eating difficulties’ are not formally classifiable within DSM IV, and within ICD 10 would fit in ‘Other Eating Disorders’ (F50.8). As a result of these developmental difficulties, and the inadequacies of the current available diagnostic systems, Bryant-Waugh and Lask (47) proposed an alternative fivecategory model for classifying eating disorders in children, which has become known as the Great Ormond Street (GOS) criteria. They propose a broadening of the description of eating disorders, to encapsulate the wide degree of variation that occurs in childhood presentations, suggesting an ‘umbrella’ definition of ‘a disorder of childhood in which there is an excessive preoccupation with weight and shape, and/or food intake, and accompanied by grossly inadequate, irregular, or chaotic food intake’ (p191). Under this umbrella description they suggest specific, developmentally sensitive criteria for anorexia and bulimia nervosa, as well as the childhood specific disorders of ‘Food Avoidance Emotional Disorder’, ‘Selective Eating’ and ‘Pervasive Refusal’.
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Food avoidance emotional disorder (FAED) This term was first coined in 1989 (48), and describes a group of children who have determined food avoidance, seemingly as a result of an emotional disorder, but which are not based on concerns around weight or shape. Unlike those with anorexia nervosa there is an acknowledgment of the weight problem and often even a stated desire to be heavier. Children presenting with FAED often have other anxiety based difficulties, such as generalised anxiety disorder, obsessive compulsive symptoms, or school refusal. This term has come to be used to describe children who are restricting food to the extent it is resulting in weight loss, excluding those with chronic low weight, and who do not endorse weight or shape concerns. There has been very little empirical study with this group, and little is known of the course or prognosis. Higg’s original study suggested a reasonable outcome in about 80% of cases.
Selective eating
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Selective eating is a term used to describe children who will only eat a very restrictive range of food stuffs. It has sometimes been described as food ‘neophobia’, or ‘perseverative feeding disorder’. Whilst there is clearly a continuum with what might be considered ‘picky eating’ or ‘fussy eating’, there are a selection of children who present with clinically significant physical, social or emotional distress or impairment as a result of the selectivity. Typically the selective eater may only eat less than 10 very specific food items, or may select their food based on unusual criteria, for example colour. Experience suggests that selective eating often, but not exclusively, occurs in the context of other neurodevelopmental difficulties such as Autism or Asperger’s syndrome. It is also important clinically to differentiate between primary and secondary selective eating, and the presence or absence of developmental disorder. As with FAED, there has been little empirical research with this group, and little is known about the long-term prognosis.
Pervasive refusal syndrome Pervasive Refusal Syndrome is a rare somatic disorder first described in 1991 (49), which manifests in a child or young adolescent appearing to ‘shut down’ over a period of time, resulting in the ultimate apparent inability to eat, drink, walk, talk or aid in any of their basic self care tasks, with no medical cause. There have been a number of proposed formulations for understanding the disorder, including a complex PTSD reaction, major anxiety disorder or a response to sexual abuse. Case descriptions in the literature suggest it can present in the first instance with anorexia nervosa symptoms and food refusal. Anecdotally there are also a number of cases of pervasive refusal syndrome where anorexia nervosa has been the primary diagnosis following remittance of the other refusal symptoms.
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Conclusions Eating disorders resembling anorexia nervosa occur in children as young as seven, of equal severity to those seen in adolescents and adults, and it is important they are recognized and treated as such as early as possible. A number of factors complicate the recognition of eating disorders in children, including a lack of expectation that weight loss may be psychological in origin, or that boys suffer from eating disorders. Although the key features of anorexia nervosa are the same across the age range, there are some differences in symptomatology and socio-demographic features in the younger age group. Bulimia nervosa is extremely rare in children, although vomiting in the context of other eating symptomatolgy occurs, as in other age groups. Current diagnostic criteria are inadequate for children and adolescence not only due to their inherent developmental insensitivity, but also due to their lack of acknowledgement of eating difficulties found specifically in childhood, such as FAED or Selective Eating. Treatment offered to young people with an eating disorder is still very much determined by the diagnosis, and in some instances the clinical and cultural context in which they present, rather than a formulation of the specific risk profile for that individual within their own developmental and systemic context. In terms of future directions and unresolved issues, the relationship between diagnosis/classification and outcome/treatment response needs to be better characterized.
References
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[31] Perkins S, Schmidt U, Eisler I, Treasure J, Yi I, Winn S, et al. Why do adolescents with bulimia nervosa choose not to involve their parents in treatment? Eur Child Adolesc Psychiatr 2005;14(7):376-85. [32] Keel PK. Purging disorder: subthreshold variant or full-threshold eating disorder? Int J Eat Disord 2007;40(Suppl):S89-94. [33] Schmidt U, Lee S, Perkins S, Eisler I, Treasure J, Beecham J, et al. Do adolescents with eating disorder not otherwise specified or full-syndrome bulimia nervosa differ in clinical severity, comorbidity, risk factors, treatment outcome or cost? Int J Eat Disord 2008; 41(6):498-504. [34] Cole TJ, Flegal KM, Nicholls D, Jackson AA. Body mass index cut offs to define thinness in children and adolescents: international survey. BMJ 2007;335(7612):194. [35] Swenne I, Thurfjell B. Clinical onset and diagnosis of eating disorders in premenarcheal girls is preceded by inadequate weight gain and growth retardation. Acta Paediatr 2003;92(10):1133-7. [36] Swenne I, Engstrom I. Medical assessment of adolescent girls with eating disorders: an evaluation of symptoms and signs of starvation. Acta Paediatr 2005;94(10):1363-71. [37] Fairburn CG, Cooper Z. The eating disorders examination, 12th ed. In: Fairburn CG, Wilson GT, eds. Binge eating: Nature, assessment and treatment. New York: Guilford, 1993:31732. [38] Couturier J, Lock J, Forsberg S, Vanderheyden D, Lee Yen H. The addition of a parent and clinician component to the eating disorder examination for children and adolescents. Int J Eat Disord 2007; 40(5):472-5. [39] House J, Eisler I, Simic M, Micali N. Diagnosing eating disorders in adolescents: a comparison of the eating disorder examination and the development and well-being assessment. Int J Eat Disord 2008; 41(6):535-41. [40] Wonderlich SA, Joiner TE, Jr., Keel PK, Williamson DA, Crosby RD. Eating disorder diagnoses: empirical approaches to classification. Am Psychol 2007;62(3):167-80. [41] Franko D, Wonderlich S, Little D, Herzog DB. Diagnosis and classification of eating disorders: What's new? In: Thomson JK, ed. Handbook of eating disorders and obesity. New York: Wiley, 2004: 58-80. [42] Katzman MA, Lee S. Beyond body image: the integration of feminist and transcultural theories in the understanding of self starvation. Int J Eat Disord 1997;22(4):385-94. [43] Anderson AE, Bowers WA, Watson T. A slimming program for eating disorders not otherwise specified: Reconceptualising a confusing, residual diagnostic category. Psychiatr Clin North Am 2001;24:271-80. [44] Crow SJ, Stewart AW, Halmi K, Mitchell JE, Kraemer HC. Full syndromal versus subthreshold anorexia nervosa, bulimia nervosa, and binge eating disorder: a multicenter study. Int J Eat Disord 2002; 32(3):309-18. [45] Williamson DA, Gleaves DH, Stewart TM. Categorical versus dimensional models of eating disorders: an examination of the evidence. Int J Eat Disord 2005;37(1):1-10. [46] Fairburn CG, Bohn K. Eating disorder NOS (EDNOS): an example of the troublesome "not otherwise specified" (NOS) category in DSM-IV. Behav Res Ther 2005;43(6):691-701. [47] Bryant-Waugh R, Lask B. Eating disorders in children. J Child Psychol Psychiatry 1995;36(2):191-202. [48] Higgs JF, Goodyer IM, Birch J. Anorexia nervosa and food avoidance emotional disorder. Arch Dis Child 1989;64:346-51. [49] Lask B, Britten C, Kroll L, Magagna J, Tranter M. Pervasive refusal in children. Arch Dis Child 1991;66:866-9.
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Section Two: History
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In: Understanding Eating Disorders Editors: Yael Latzer, Joav Merrick, Daniel Stein
ISBN 978-1-61728-298-0 © 2011 Nova Science Publishers, Inc.
Chapter 4
A Historical Background to Current Formulations of Eating Disorders
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Eliezer Witztum, MD1, Yael Latzer, DSc2 and Daniel Stein6, MD3 The aim of the present chapter is to understand the role of socio-cultural processes in the predisposition to eating disorders (EDs) in the context of their historical background. For this purpose we did a systematic literature search to investigate historical and contemporary socio-cultural perspectives relevant to anorexia nervosa (AN) and bulimia nervosa (BN). Symptoms and syndromes of self-starvation have been observed for hundreds of years, being interpreted according to the prevailing beliefs and cultural norms of each era. Our historical review uncovers two central themes relevant to AN: an ascetic-religious aspect of fasting, in which self-starvation serves as a means of purifying the body of the sins of the flesh, and a physical, esthetic aspect focused on appearance and the ideal of beauty. By contrast, BN as it is currently defined is a relative new syndrome that is not akin to descriptions of bingeing behaviors in previous eras that have not included compensatory purging behaviors and fear of fatness. Our historical review proposes that EDs can be regarded as an idiom of distress, in that in many (although not all) societies and eras, they have served women as a mean to express their pain and to cope with issues related to individuality, autonomy, equality, and social position.
1 Beer
Sheva Mental Health Center and Psychiatry Division, Faculty of Health Sciences, Ben Gurion University of the Negev, Beer-Sheva 2 Eating disorders Clinic, Psychiatry Division, Rambam Medical Center and School of Social Work, Haifa University, Haifa 3 Pediatric Psychosomatic Department, Edmund and Lily Safra Children’s Hospital, Chaim Sheba Medical Center, Tel Hashomer and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel 7 Correspondence: Daniel Stein, MD, Pediatric Psychosomatic Department, Chaim Sheba Medical Center, IL52621 Tel Hashomer, Israel. E-mail: [email protected].
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Introduction Anorexia nervosa (AN) and bulimia nervosa (BN) are currently considered to represent major clinical problems in many countries of the Western world. The frequency of these disorders has been rising in the second half of the 20th century (1) and has now attained epidemic proportions. Eating disorders (EDs) occur primarily in adolescent girls and young women, during a crucial developmental stage, and are linked to extensive morbidity and high mortality rates (1). Anorexia nervosa (AN) has been traditionally linked with a host of sociocultural motives, with many descriptions of the disorder appearing over the years. By contrast, the evidence for a binge–purge syndrome outside of its present historical context is quite sparse (2). The causes for the development of disordered eating syndromes are still unclear, yet they likely represent a multi-determined etiology. The present article focuses on the socio-cultural conceptualization and interpretation of EDs in different periods in the history of mankind, and discusses whether the development of these aberrant psycho-physiological disturbances can be conceptualized in terms of them representing an idiom of distress.
Anorexia Nervosa (AN)
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Historical background The survey of the historical background of EDs demonstrates that symptoms and syndromes of self-starvation are not new, modern phenomena reaching epidemic proportions in young women in recent years alongside the surge in the influence of the thin body ideal among women in many Westernized cultures. Rather, they have been observed and known for many years, being interpreted and understood according to the prevailing beliefs and cultural norms of each era. In the following section, we will describe significant landmarks in the history of self-starvation, with a specific emphasis on the motivations for self-starvation in different eras.
The classical period and Gnostic asceticism Interestingly, self-starvation was a virtually unknown phenomenon in the classical world. Some descriptions of cases of vomiting after eating date from the Roman period, but no behaviors reminiscent of anorexia nervosa are mentioned. It is only when European culture begins to be influenced by Eastern religions that descriptions of extreme behaviors related to fasting and self-starvation appear (3). These religions preached a dichotomy between the material world as perceived by the senses, and an eternal, sacred reality of the soul, trapped as a prisoner within the body. The body, with all its material attributes, was seen as “essentially evil”, while the soul trapped inside it was an entity representing the “eternal good”, which had become separated from the deity at some point (4). The Gnostic sects, who became particularly popular following the Roman conquest of Greece, advocated this type of doctrine, claiming to possess the wisdom and knowledge
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(gnosis) that would lead to the true road to salvation, in a world that was basically evil and corrupt. The Gnostic belief in the dichotomy between the evil, corrupt material world and the inner spiritual entity had a profound effect on the early Christians, who chose to withdraw from the sinful city life to remote, secluded sites. The practice of self-starvation as a technique for purification and spiritual seeking is found in descriptions of the lives of the first Christian monks, such as Hilarion and his contemporaries. Under Christian guise, Gnostic ideas infiltrated the Roman world. For example, St. Jerome, translator of the Bible from Hebrew into Latin, became the spiritual ‘guru’ of a group of wealthy Roman women in the fourth century AD. Records tell of a young Roman girl from an upper-class family who fasted to her death as a result of the implementation of his extreme ascetic doctrine – possibly the first documented instance of anorexia nervosa. Due to her death, Jerome was forced to flee from Rome to Bethlehem (3). The Gnostic-Christian attitude of despising the material body as a source of evil and an obstacle on the path to redemption left its mark on European culture for hundreds of years, and remains significant even in today’s secular modern world.
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The early middle Ages 5th – 10th centuries) The early middle Ages began as the Roman Empire collapsed and Hellenic culture declined. Europe endured difficult times, beginning in the fifth century, marked by barbarian invasions, disasters, and destruction, accompanied by plagues and famine. In the sixth century, the population of Rome dwindled from several hundred thousand residents to 30,000. Over this period, there are only a few reported cases (three) of young women starving themselves. Two cases under similar circumstances, from the fifth and eighth centuries AD, were interpreted as possession by the devil and cured through contact with sacred objects, leading to the ‘exorcism’ of the demonic agent (3,5). The third case is particularly interesting, in that contrary to the previous cases, its heroine was elevated to the status of a saint. Wilgefortis, whose name meant ‘iron strong maiden’, daughter of the king of Portugal, lived sometime between the eighth and tenth centuries. She was renowned for her beauty, and her father promised her in marriage to the king of Sicily. However, the princess decided to devote herself to the service of the Christian church, and embarked on a strict regime of prayer, asceticism, and self-starvation, pleading to God to take away her beauty. Soon her began to grow hair (lanugo?) on her face and body, and the prospective groom changed his mind. Wilgefortis was crucified as punishment for the cancellation of her wedding. On her way to the cross, she is said to have reminded all women of the heavy burden of passions and desires in their lives. She was perceived as a paragon of devotion and self-sacrifice, and declared a saint. Her story illustrates the psychological hardship, the conflicts surrounding femininity, and the problems in defining her own identity experienced by a young girl wishing to preserve her maidenhood and avoid marriage. Wilgefortis’s tendency to seclusion and asceticism and her desire to remain virginal were embraced by the church of the time as virtues to be emulated (5). Lacey (5) argues that the popularity of the story of Wilgefortis reflects the presence of AN throughout the European countries in which the bearded saint has received different names A similar story occurred 300 years later, when Margaret, daughter of the king of Hungary, preferred to die of self-starvation at the age of 28 years rather than marry as her
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father had decreed. As in the preceding case, her behavior was idealized by the church, and she was canonized five years after her death (6).
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The late middle ages, the renaissance, and “holy anorexia” (the 12th – 16th centuries) Margaret’s story takes place in the thirteenth century, marking the beginning of an avalanche of tales of voluntary self-starvation, particularly in southern Europe. In his book, Holy Anorexia, Bell (7) collected 181 reported cases of ‘sainted’ young women who starved themselves, often to death, between 1200 and 1600. In contrast to the rarity of these incidents during the early Middle Ages, forms of anorexic behavior became common towards the end of the Middle Ages and during the Renaissance. A considerable number of the women involved became ‘saints’, and their biographies were circulated by their priest-confessors as an example to others. One example of this pattern can be seen in the story of St. Catherine of Sienna, born in 1397, the twentyfourth daughter of a prosperous merchant family. Catherine began fasting at the age of 16 years subsequent to two tragic events that occurred in rapid succession – the death of a beloved older sister in childbirth, and the death of a younger sister. Shortly afterwards, Catherine, who had reached marriageable age by the standards of her time, was required by her parents to marry. She refused; confronted with the objections of her family, she starved herself, spent long hours in devout prayer, and punished her body with flagellation and other forms of self-abuse. Eventually her parents relented and allowed her to retreat into life as a nun, outside the convent, until her death from malnourishment at the age of 32 years. During her lifetime, because St. Catherine was a prolific writer, much is known about her internal experience of self-starvation. She refused to eat because she viewed herself as afflicted by an inability to eat. Instead, she devoted herself to caring for the sick, the poor, and the miserable, in complete self-negation and disregard for her own needs. Her need for absolute control can clearly be seen in some of the stories about her, as well as the total suppression of bodily urges (7). There were cases of other women who refused eating for “divine” reasons and were claimed as saints. Despite the acceptance of divine intervention as the reason for selfstarvation in these cases, According to Bell (7) and Bynum (8), peers and superiors of the fasting saints repeated attempted to induce these women to eat, sometimes even by force, to avoid the sin of vainglory, an inability to engage in holy responsibilities, or the sin of suicide. The high rate of anorexic behaviors during the Renaissance period may be attributable to the pervasive changes that were taking place in everyday life and cultural values. These transformations have stemmed from the material developments, wealth, and sophistication of the period. For example, inventions and progress in agricultural techniques initiated in the eleventh century have gradually brought about a significant improvement in the welfare and nutritional state of the general population. Concurrently, trade with the East has developed, bringing cultural influences with it. Flourishing city-states such as Genoa and Venice have emerged, with a social class of wealthy citizens who cultivate esthetic values and the arts. Although women have remained subjugated to men, performing the traditional roles of wife and mother, they could still enjoy a greater degree of power and freedom of choice. Burckhardt (9), an acclaimed researcher of the Renaissance, believes that women of the time
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have been provided with an education equal to that of men. The ideal of feminine beauty has also changed during this period. The shift in perception is evident in paintings, particularly in the portraits of partially nude women, surrounded by their toiletries (9). This is a time reminiscent of our own, in which material plenty, opportunities, and greater freedom have allowed women to rebel against their traditional roles, while engendering a heightened preoccupation with external appearance.
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From the Renaissance to the Victorian period (the 17th-18th centuries) Women’s freedom declined again at the end of the Renaissance and virtually disappeared during the Reformation, as puritan Protestant values returned women to their traditional status. The Catholic Church also adopted a conservative stance and attempted to curtail all unorthodox forms of ritual and religious devotion, emphasizing the rigid hierarchy extending from the simplest priest to the Pope, the sole representative of God on earth. During this period, a woman displaying anorexic behavior would not be venerated or canonized; on the contrary, her behavior would be interpreted as a perversion or a heretical act, possibly even a cause for a visit from an Inquisitor (3,8). Despite these cultural changes and the dramatic decline in the rate of anorexic behavior, cases of self-starvation with a background of religious asceticism still appeared in the 17th century, particularly within unique groups with amenable ideologies, such as fundamentalist cults (10). In the 18th century, behaviors related to fasting and self-starvation in women have gained great attention in the popular media throughout Europe and America (3,11,12). Several cases have been described in this period in the popular media, all similar in their circumstances, recalling tales of a modern-day Cinderella. The heroine is usually a girl from the lower classes in a rural area, who claims to be able to subsist without food and drink. The astounding news spreads through the region and the girl becomes a celebrity, frequently placed on display by her family, generally for payment. Some fasting girls have been even acclaimed as miracles, termed the” miraculous maids”. Their ability to eat nothing yet remain completely healthy (including maintaining a normal weight), was ascribed to them being miraculously nourished by the angels (3) At times, however, these incidents turned out to be fraudulent, with family members covertly providing food. Other cases ended tragically, with the death of the “heroine” from complications of malnutrition. A typical example is the case of Sarah Jacobs, the “Welsh Fasting Girl,” in 1889 (3,11,12), which became the focus of ideological and theological debate. Religious leaders used the story as proof of the belief that the human body is eternal, while scientists maintaining a biological-medical viewpoint claimed that man was no different from beasts, and that the human body had material needs just like the rest of the animals. Sarah was one of seven children in a family of small farmers in Wales. She began to fast in 1867 at the age of 12 years. Upon reaching marriageable age, she claimed to have ceased needing any food or drink. The case quickly gained publicity. Sarah’s parents dressed her in extravagant clothes and charged a fee for the right to see and photograph her. However, certain physicians who were skeptical about the veracity of the tale sent a delegation of four nurses with the assignment of supervising Sarah and ascertaining that she truly was not receiving any food. After six days of observation she became very weak. The nurses urged her father to call for
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medical assistance, but he refused. Four days later Sarah died of complications caused by malnutrition, and her father was charged with criminal neglect. The autopsy discovered fecal material chronologically matching the period before the nurses’ arrival, leading to the conclusion that prior to their visit Sarah had succeeded in obtaining nourishment from some source. This case, and the controversy it aroused, garnered immense publicity and had the effect, for a while, of causing a wave of imitations by young girls throughout the British Isles. The explanatory model for the interpretation of self-starvation in young women gradually shifted during the second half of the 18th century, from the spiritual and theological realm to the medical domain and towards perception of the behavior as an illness – initially a physical illness, and later a mental illness. Nine doctoral dissertations written between 1685 and 1770 (13) attempted to identify medical causes of the disease, offering various organic explanations, such as flaws in the neural supply to the stomach, or a defect in the sensitivity of the brain to neural signals from the stomach. The concept of anorexia as a mental disorder first appeared during this period, and gained a great deal of popularity as a result of a monograph written by Richard Morton in 1689. Morton (14) described two cases, an 18 year old girl and a 16 year old boy, that suffered from a condition he termed nervous atrophy or a nervous consumption. Both were characterized by loss of appetite, extreme emaciation, amenorrhea, extensive studying and overactivity, and indifference to the condition.
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The Victorian period (the 19th century) Several characteristics of the Victorian era show similarities to the Renaissance period in Italy. The industrial revolution led to a transition from villages to cities, resulting in urbanization and the creation of a bourgeois middle class. Education increased in importance; esthetic values were cultivated; the empirical sciences made impressive progress; great advances occurred in medicine. Women’s status began to change; women entered professions previously considered exclusively masculine. Perceptions of women changed, along with the ideal of feminine beauty. As a consequence of this cultural climate, reports indicating an increasing frequency of EDs began to appear in the nineteenth century. The idea that “voluntary” self-starvation was a genuine medical disorder, distinct from other EDs, became the established medical opinion. Initially, reports described EDs in the form of vomiting and self-starvation due to complaints such as “food sticking in the throat” or an inability to eat due to “stomachache”. These disorders were interpreted and conceptualized as expressions of hysteria (15). Several detailed clinical descriptions of a disorder associated with voluntary selfstarvation despite pangs of hunger, were written independently, mainly in the second half of the 19th century, in Europe. Although the reports of Lasegue (16) and Gull (17) are the most cited, similarly important contributions were made by Imbert [cited in Vandereycken and Van Deth (14)], Chipley (18) Marce (19), and Brugnoli [cited in Habermas 1992 (20)]. The name ‘anorexia nervosa’ to describe self-starvation as a distinct clinical entity was introduced for the first time by Imbert, and later by Gull. At the end of the nineteenth century, American physicians were beginning to differentiate anorexia as a clinical syndrome distinct from the larger category of hysteria (21), and German physicians were differentiating AN from the larger category of neurasthenic disorders (22).
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The descriptions of these clinicians resembled present-day AN in that the patients were primarily women between the ages of 15 and 20 years, the syndrome focused on active and deliberate food refusal, and a great emphasis was put on the consequences of loss of weight and fat tissue and on the presence of amenorrhea. Marce (19) and others (23) noted that deliberate food refusal and resistance to treatment could lead to death in some cases, but that patients could be cured if forcibly reefed. The diagnosis of anorexia became quite popular in the second half of the nineteenth century. Freud, in a letter to his friend Fliess in 1895 (24), noted that the widespread diagnosis of AN in young girls appeared to him, after careful consideration, as a type of melancholy, which occurs when sexuality is insufficiently developed. Freud’s viewpoint provides an example of an interpretation that attempts to adapt the reality of the illness to his psychoanalytic beliefs, emphasizing the significance of the psychosexual foundation of the development and creation of psychopathology. Parry Jones (23) found evidence of 40 cases of AN among 36,000 hospital admissions in England, suggesting that 0.1% of psychiatric inpatients may have suffered from AN.
The 20th century In the early twentieth century, there were two major currents in the interpretation of EDs:
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The psychogenic approach: The psychoanalytic view that prevailed at the start of the 20th century – attempted, following Freud’s formulations, to understand the refusal of AN girls to eat as “an expression of defenses against frightening unconscious sexual wishes for oral impregnation”. Later, as psychoanalytic theory developed, AN behavior was conceived of as the expression of a narcissistic wound during adolescence, leading to the activation of repressed urges originating in the oral phase (25). The object relations theory viewed AN as an expression of confusion and a lack of boundaries between the girl’s body and internalized “bad” objects, whereas the more recent self-psychology conceptualization interpreted the disorder as the result of serious damage to the sense of self, in which eating, or not-eating, are considered maneuvers to improve self-esteem (26). Thus, psychogenic interpretations of AN, as of any mental disorder, likely reflect, at least to some extent, the theoretical paradigms prevalent at the time of their conceptualization. The organic approach: In the work of Simmonds (27), a German physician who was the first to describe the post mortem findings of a patient with extreme thinness, the autopsy revealed a destroyed pituitary gland. This led Simmonds to note the clinical similarity between AN and cases of pituitary degeneration. This interpretation led to a massive wave of treatments of AN patients with a variety of endocrinological substances. Later studies refuted this approach, pointing out the differences between the two conditions, noting that damage to the pituitary in Simmond’s patient was likely the result of the illness, rather than its cause (2).
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Current formulations From the mid-1960s onwards, empirical research of EDs has flourished considerably, likely reflecting the surge in the incidence of these disorders in the second half of the 20th century (1). These studies have led to the first description of bulimia nervosa (BN) by Russell in 1979 (28), as a clinical entity that is different from AN, and to the subdivision of AN into restricting and bingeing/purging spectrums in the early 1980s (29). Binge eating disorder has been described as a separate entity in the early 1990s (30). EDs are currently considered as distinct clinical disorders that are the result of a complex interaction of multi-dimensional genetic, physiological, familial, cognitive, psychological, personality, and socio-cultural dimensions (31).
Bingeing/purging eating disorders
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Historical background In our review of the history of AN, we found over the years numerous examples of young women engaging in self-starvation. What was different in diverse historical periods was the motivation behind food refusal. In contrast, evidence of a bingeing/purging syndrome outside of its present historical context is quite sparse (2). Historical accounts of bulimia do not seem to preponderate in adolescent or young adult females. In fact, prior to the nineteenth century, cases involved mostly adult men. Further, most historical cases of bulimia actually represent binge-eating without compensatory purging behaviors. Russell who was the first to relate to BN as a distinct clinical entity (28) also claimed that " It is not possible to write a truly historical account of bulimia nervosa as the diagnostic term was coined as recently as 1979, and there is therefore no true historical era available for study" (32). Nevertheless, in a recent paper devoted to 25th Anniversary of BN (33), Russell considered the claim that BN in its current definition is a new disorder (e.g., 2) as over inclusive, because in his opinion the study of the history of BN has hitherto been neglected and subject to considerable controversies. For these reasons we have decided to relate in our review to the history of binging/purging EDs, rather than to the history of BN. Several authors have reviewed historical cases of "bulimia" prior to its formal recognition in the late 1970th. Four cases have been described before the second century CE, i.e., the Roman emperors Claudius (41–54 CE) and Vitellius (circa 69 CE). Most researchers (34,35) speculate as to whether these emperors have suffered from any clinical disorder. This because excessive food intake among the elite in the Roman Empire appeared to be based on intentional indulgence, with self induced vomiting used as a means to allow continued consumption. Nevertheless, a not entirely volitional pattern was apparently noted in some cases (34). In the eighth century CE, Avicenna prescribed self-induced vomiting to undo the ill effects of overeating; however, he warned, that "to procure vomiting to an undue degree is injurious for the stomach, thorax and the teeth . . . and may lead to consumption". According to the Arab medicine at that time, the custom of some people who eat to excess and then procure vomiting is one of the things that end in a chronic disorder (36).
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From the twelfth to the seventeenth centuries, many of the fasting saints were reported to engage in binge eating (e.g., St. Veronica) and self-induced vomiting (e.g., St. Catherine) (7). However, these cases appear to fall within the current diagnosis of bingeing/purging AN subtype, rather than presenting with true BN. In the seventeenth century, there appeared a description of a 50-year-old man (1678) who experienced uncontrollable eating followed by vomiting 20 days each year, and, following the 20-day bingeing/purging cycle, he fasted for 20 days and then resumed normal eating throughout the remainder of the year (35). Dr. Richard Lower (1631–1691), in apparently the first medical description of a bingeing or a bingeing/purging disorder, observed in the 17th century “an uncommon hunger” (fames canina) among patients with hypochondria and hysteria that produced in some cases “a great craving for food” [as cited in Silverman (37)], whereas in other cases consuming large amounts of food was followed by vomiting (38). Parry-Jones and Parry-Jones (39) reviewed 12 potential cases of BN from the seventeenth to nineteenth centuries. Most of these cases, however, were apparently not associated with inappropriate compensatory behaviors, and parasitic worms were found in some of them. In the eighteenth century, Parry-Jones (40) detailed the case of Samuel Johnson from 1784 as meeting criteria for BN. Johnson engaged in binge-eating episodes that caused him to be significantly overweight. To control his weight, he engaged in fasting and used senna as a purging agent. However, Johnson’s use of fasting and purging seemed quite time-limited compared with his long-standing pattern of compulsive overeating. In the 19th and early 20th century, repeated medical descriptions have appeared of women who engaged with some form of a mixture of bingeing, vomiting, and restricting behaviors. However, in most of these cases a clear cut definition of BN could not be established. This because these women either suffered mainly from binge eating behaviors, or the cycles of bingeing and purging were not concomitant, or their weight was definitely reduced. Rosenvinge and Vandereycken (41) reviewed a case of “hysteria” described by Selmer in 1892 in which a 12-year-old girl refused to eat but maintained normal weight. This apparent contradiction was explained one night when the girl’s mother observed her “eating butter, herrings, potatoes and all the food she was able to find in the house”. Thus, as is also common nowadays, this girl appeared to fast during the day and binge-eat at night. A report in 1870 describes a 14-year-old girl who would fast for 18 days and then enter a period during which she ate voraciously (39). In this case, extended periods of binge eating alternated with extended periods of fasting rather than there being a cycle of binge-eating coupled with inappropriate compensatory behavior. Habermas (42) presents Ludwig Binswanger’s description of Irma, published in 1909, as “the first known report on a case of bulimia nervosa at normal body weight”. Habermas’s (43) review of Briquet also reveals a case of so called BN in a woman who “ate well” but vomited everything she had eaten and maintained a normal weight”. Van Deth and Vandereycken (44) reviewed 19th century cases of hysterical vomiting, mostly occurring in female adolescents, and noted that some cases occurred in individuals of normal weight who also engaged in binge eating and fasting behaviors. However, the authors equated these cases more with a modern-day conversion disorder, psychogenic vomiting, or AN-bingeing/purging type rather than with BN. A similar uncertainty emerges in the review of Pope et al (45) of four individuals presented by Pierre Janet in 1903, who had binge eating behaviors, but purging behavior was present only in one case. Following their review of
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Janet’s cases, Pope et al (45) concluded that the major psychiatric texts of the nineteenth century, including those of Esquirol (1838), Briquet (1859), and Lasegue (1873) included no true cases of bulimia. The most prominent descriptions of probable examples of BN in the earlier half of the 20th century were the case histories of Ellen West (46), and Laura (47). Again, some argue that these women should have actually been diagnosed with other types of EDs rather than with true BN (48). To summarize, modern BN, i.e., a syndrome characterized by concomitant bingeing, purging, and fear of fatness has been described only since the 1970th, at first as a variant of AN, and only later as a distinct ED that appears in normal-weight women. Most of the historical cases of bulimic syndromes, in which extended periods of binge eating have alternated with extended periods of dieting, resemble a pattern that is closer to the current diagnosis of binge eating disorder than to genuine BN.
Discussion
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Anorexia nervosa Traditionally, AN has been conceptualized to represent a culture-dependent syndrome (10), namely a syndrome that cannot be understood separated from its cultural context (49) and that is restricted to a limited number of cultures by virtue of psychosocial factors (50). Studies supporting this view have flourished since the 1960th, emphasizing that the increase in the frequency of AN in young women in Western cultures in our era is the result of a similar increase in the influence of socio-cultural norms such as the importance of slimness, youth, personal achievement, individualism, and women’s self-definition (51). More recent studies, however, cast doubt as to the definition of AN as culturally dependent, as its current prevalence in many non-Westernized countries is often similar to that found in Western countries, and the recent increase in its incidence in Western countries likely reflects greater use of treatment facilities rather than being a genuine change (2). Another line of conceptualization relates to the occurrence of AN in societies in transition that undergo considerable socio-economic and socio-cultural changes (52), or to its emergence in places where it has not been described before (53). According to this conceptualization, what is detrimental is not so much the maladaptive influence of a specific culture to predispose to an ED. Rather, it is the changes that occur within a Westernized culture that idealizes thin physique (52), or within cultures that are abruptly exposed to this ideal for the first time (53) that increase the risk to develop disordered eating, as these may interfere with the cultural conditions required for the development of a stable identity (54). In line with the relevance of socio-cultural changes in the predisposition to AN, we propose that relating to the changes in the socio-cultural meaning of AN over time as representing an idiom of distress, may be of additional relevance in understanding the disorder from its historical perspectives. Whereas the conceptualization of AN as culturallydependent likely stands in contrast to the high influence of genetic/biological determinants in the predisposition the disorder, conceptualizing AN as an idiom of distress, as we propose, can be well -intergraded into genetic/biological formulations.
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The term idiom of distress has been introduced for the first time by Nichter (55). This conceptualization emphasizes that people in different cultures may express their distress and deal with its consequences in different ways (55,56) that reflect the meaning that a culture gives not only to the distress itself, but also to the mode in which it is expressed (57). Problems may find their expression in a range of symptoms at the various levels of human experience: physical, behavioral, emotional, experiential, cognitive, and interpersonal. Whereas the enactment of a cultural idiom of distress may help to resolve or give meaning to one form of illness or distress, it may cause or exacerbate other forms of suffering depending on how it is used and articulated by any given individual in any given society (57). The use of physical symptoms and syndromes as an idiom of distress to overcome and give meaning to emotional suffering has been described in a host of psychopathological disturbances, including somatization disorders, psychosomatic disorders, depression (58), and anxiety (59). EDs have served women as an arena in which they can express their pain, uniqueness, and individuality. Although we have not found any reference to EDs as idioms of distress in an extensive review of the literature, this type of expression is in our opinion of great relevance in the context of AN. The culture participates in the construction of an idiom of distress in processes that shape the emotions of an individual via a system of shared symbols, norms, and social institutions. Direct, free expression of emotions such as aggression or sexuality or of emotions in general, is denied in certain cultures. The social, emotional, and mental distress of people may then be channeled, sometimes neutralized, and directed towards alternative modes of expression that are legitimate and in line with the values and expectations of the respective cultures. A common means of handling expressions of distress is by redirecting them to the physiological plane (56), in our case self-starvation and/or weight reduction. Our historical survey illustrates that the syndromes and symptoms related to AN were observed and noted throughout human history, but were interpreted in accordance with the beliefs and cultural norms of each era. Heightened rates of AN were seen during periods without famine or food shortage – times of economic plenty, during which women’s status was altered. Traditional society changed, and women obtained education and greater freedom, which allowed them to rebel against their traditional roles. Our historical review seems to uncover two central themes relevant to AN: an asceticreligious aspect of fasting, in which self-starvation serves as a means of purifying the body of the sins of the flesh, and a physical, esthetic aspect focused on appearance and the ideal of beauty. Similarly, Habermas (43) has argued that modern-day AN extends to historical cases presented in the latter half of the nineteenth century by Gull, Lasegue, and Marce, but not to the fasting found among medieval religious ascetics or Victorian-era fasting girls. Self-starvation as a means to improve self-esteem and achieve personal meaning seems to be of importance mainly in recent decades, although many modern AN patients do present with the trait of “medieval asceticism”. By contrast, the conceptualization of self-starvation as liberating individuals from unwanted burdens and from sins of flesh, and bringing them closer to their spiritual core in complete self-negation of their personal needs, has been described throughout history. It should be, nevertheless, noted that cases of “spiritual starvation” (10,60), i.e., women who fast to engender spiritual purity are found also nowadays. Whereas in Christianity mostly women endorse self-starvation as a means for
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individual purification, in Judaism, it is the “Zadik”, the chosen male individual, who fasts to atone for the sins of the entire community (59). In some cases a process of formalization of an idiom of distress into a distinct illness may occur over time. Such a formalization has been suggested to play a part in the construction of AN as a separate homogeneous clinical entity since the first clinical descriptions in the second half of the 19th century, i.e. as an active attempt towards ego-syntonic emaciation due to deliberate self starvation that is the result of personal rather than collective ascetic-religious motives (1,8,43). Formalization occurs through the creation of a socio-cultural model which includes an etiological explanation of the disorder, its characteristic symptoms at the behavioral and emotional levels, and accepted methods of treatment (in accordance with the interpretations of the period). In our era, conflicts at the collective and individual sociocultural levels, i.e. between the opulent consumer society and the feminine esthetic ideal of thinness, can be channeled in individuals who are predisposed because of genetic, personality and other vulnerabilities into a formal expression of the idiom of distress in terms of AN.
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Bulimia nervosa In contrast to AN, BN is still conceived to represent a culturally dependent syndrome. This because numerous epidemiological studies have shown the occurrence of a sharp increase in the incidence of the disorder in Westernized countries in the latter half of the 20th century. Moreover, the appearance of BN in non-Westernized cultures is still infrequent, and almost always in the context of some exposure to Western thin body-ideal norms (2). One possible reason for this difference between AN and BN is that being a new syndrome, it might take time for BN to spread to non-Western societies as well. Concerning our idiom of distress model, BN represents one example in which the enactment of a cultural idiom of distress may actually exacerbate rather than decrease suffering (57), as BN women often regard themselves as unable to control neither their eating nor their weight. Keel and Klump (2) propose that in line with the restraint hypothesis, in which bingeing may occur following extensive restricting, one would expect that the fasting evident in medieval women diagnosed with “holy anorexia” would result in binge eating in at least some of these young women. Consistent with this hypothesis, there have been indeed isolated cases in which individuals have engaged in binge eating after a period of restricted food intake. However, the use of purging (or other forms of inappropriate compensatory behaviors) to counteract or undo such bingeing episodes was lacking in most reported cases. The difference between medieval and modern BN may be explained by the motivation behind food restriction. In modern times, food restriction is often intended to achieve weight loss. When a binge episode occurs, purging is motivated by the belief that it will prevent weight gain. Conversely, if fasting is interpreted in a religious framework as has been the case in medieval times, then purging cannot prevent the sin of gluttony once the binge episode has occurred (8). Keel and Klump (2) additionally suggest that whereas modern AN may be the result of motivations related to weight concerns, this has not been the case in the medieval asceticreligious self-starvation. We propose that preoccupation with weight in our era can be conceived as an idiom of distress in European and North-American young women who are constantly exposed to and required to handle weight–related socio-cultural pressures. By
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contrast, self-starvation in women in living in the Far-East is connected to a significantly lesser extent with weight-related concerns and body image disturbances (61). From a different perspective, Keel and Klump (2) suggest that in contrast to AN, a bingeing/purging syndrome predominantly affecting normal-weight women can emerge only in the context of fear of fatness. Whereas historical and modern “bulimia” differ in the preoccupation with weight criterion (2), such a dichotomy between AN and BN is in our opinion not always the rule. Many restricting patients develop bingeing/purging behaviors within several years (62), and AN and BN present a shared vulnerability in important aspects, including their genetic transmission or the resemblance in enduring personality attributes in recovered patients (63).
Conclusion
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EDs likely reflect complex, inter-dependent, multi-dimensional causalities (31). Dieting behaviors may be propelled into a full-blown disorder by an interaction of antecedent genetic, biological, psychological, familial and socio-cultural influences. EDs have been traditionally conceptualized as socio-cultural dependent syndromes, related primarily to the thin body ideal, and being of relevance predominantly in wealthier industrialized Western countries (10). More recent theories regard EDs as a cultural byproduct of modernity that cuts across geographic and economic lines in vulnerable individuals, rather than being a strictly Western phenomenon (52). EDs may, thus, be attributed to a combination of socioeconomic development, changing roles of women, a socio-cultural emphasis on thinness, and a shift in eating patterns (52), that affect predisposed women that share genetic, physiological and psychological vulnerabilities. The paradigm of idiom of distress seems of particular relevance in translating these macro socio-cultural processes into the suffering of each and every individual woman.
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[11] Brumberg JJ. Fasting girls: The histories of anorexia nervosa. New York: Penguin Books, 1988. [12] Vandereycken W, Van Deth R. From fasting saints to anorexic girls: The history of selfstarvation. New York: New York Univ Press, 1994. [13] Bliss EL, Branch CHH. Anorexia nervosa: Its history, psychology, and biology. New York: Paul Hoeber, 1960. [14] Morton R. Pthisiologia: Or a treatise of consumptions. London: Smith Walford, 1694. [15] Liles EG, Woods SC. Anorexia nervosa as viable behavior: Extreme self-deprivation in historical context. History Psychiatry 1999;10:205-25. [16] Lasegue C. De l'anorexie hysterique. Arch Gen Med 1873;21:385-403. [17] Gull W. Anorexia nervosa. Trans Clin Soc London 1874;7:22-31. [18] Chipley W.J. (1860). On sitomania. J Psychol Med Ment Pathol 1860;13:266–70. [19] Marce LV. On a form of hypochondriacal delirium occurring consecutive to dyspepsia, and characterized by refusal of food. J Psychol Med Ment Pathol 1860;13:264–6. [20] Habermas T. Historical continuities and discontinuities between religious and medical interpretations of extreme fasting: The background to Giovanni Brugnoli’s description of two cases of anorexia nervosa in 1875. Hist Psychiatry 1992;3:431–55. [21] Vandereycken W, Lowenkopf EL. Anorexia nervosa in 19th century America. J Nerv Ment Dis 1990;178:531–5. [22] Vandereycken W, Habermas T, Van Deth R, Meermann, R. German publications on anorexia nervosa in the nineteenth century. Int J Eating Disord 1991;10:473–90. [23] Parry-Jones WL. Archival exploration of anorexia nervosa. J Psychiatr Res 1985;19:95– 100. [24] Freud S. The origins of psychoanalysis. New York: Basics Books, 1959. [25] Walter JV, Kaufman MR, Deutsch F. Anorexia nervosa: A psychosomatic entity. Psychosom Med 1940;2:3-16. [26] Bachar E. The Fear of Occupying Space. Jerusalem: Hebrew Univ Magnes Press, 2001. [27] Simmonds M. Uber embolische Prozesse in der Hypophysis. Arch Path Anat 1914;217:226. [28] Russell GFM. Bulimia nervosa: An ominous variant of anorexia nervosa. Psychol Med 1979;9:429-48. [29] Strober M, Salkin B, Burroughs J, Morrell W. Validity of the bulimia-restricter distinction in anorexia nervosa. Parental personality characteristics and family psychiatric morbidity. J Nerv Ment Dis 1982;170:345-51. [30] American Psychiatric Association. Diagnostic and statistical manual of mental disorders (4th ed, text rev). Washington, DC: APA, 2000. [31] Halmi KA. Eating disorders in females: genetics, pathophysiology, and treatment. J Pediatr Endocrinol Metabol. 2002;15(Suppl 5):1379-86. [32] Russell GFM. The history of bulimia nervosa. In: Garner DM, Garfinkel PE. Handbook of treatment for eating disorders (2nd ed). New York: Guilford, 1997:11-24. [33] Russell GFM. Thoughts on the 25th Anniversary of Bulimia Nervosa. Eur Eating Disord Rev 2004;12:139–152 [34] Crichton P. Were the Roman emperors Claudius and Vitellius bulimic? Int J Eating Disord 1996;19:203–7. [35] Ziolko HU. Bulimia: A historical outline. Int J Eating Disord 1996;20:345–58. [36] Nasser M. A prescription of vomiting: Historical footnotes. Int J Eating Disord 1993;13:129–31. [37] Silverman JA. Robert Whytt, 1714–1766, eighteenth century limner of anorexia nervosa and bulimia, an essay. Int J Eating Disord 1987;6:143–6.
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[38] Stein DM, Laakso W. Bulimia: A historical perspective. Int J Eating Disord 1988;7:201–10. [39] Parry-Jones B, Parry-Jones WL. Bulimia: An archival review of its history in psychosomatic medicine Int J Eating Disord 1991;10:129–43. [40] Parry-Jones B. A bulimic ruminator? The case of Dr. Samuel Johnson. Psychol Med 1992;2:851–62. [41] Rosenvinge JH, Vandereycken W. Early descriptions of eating disorders in the Norwegian medical literature. Acta Paedopsychiatr 1994;56:279–81 [42] Habermas T. The role of psychiatric and medical traditions in the discovery and description of anorexia nervosa in France, Germany, and Italy, 1873–1918. J Nerv Ment Dis 1991;179:360–5. [43] Habermas T. The psychiatric history of anorexia nervosa and bulimia nervosa: Weight concerns and bulimic symptoms in early case reports. Int J Eating Disord 1989;8:259–73. [44] Van Deth R, Vandereycken W. Was late-nineteenth-century nervous vomiting an early variant of bulimia nervosa? Hist Psychiatry 1995;6:333–47. [45] Pope HG, Hudson JI, Mialet JP. Bulimia in the late nineteenth century: The observations of Pierre Janet. Psychol Med 1985;15:739–43. [46] Binswanger L. The Case of Ellen West (trans. by Werner M. Mendel and Joseph Lyons) In: May R, Angel E, Ellenberger H. Existence: A new dimension in psychiatry and psychology. New York: Basic Books, 1958:237-364. [47] Lindner R. "Solitaire -The Story of Laura". In: The Fifty-Minute Hour. New York: Bantam Books, 1955:79-118. [48] Habermas T. Further evidence on early case descriptions of anorexia nervosa and bulimia nervosa. Int J Eating Disord 1992;11:351–9. [49] Swartz L. Anorexia nervosa as a culture-bound syndrome. Soc Sci Med 1985;20:725-30. [50] Prince R. The concept of culture-bound syndromes: Anorexia nervosa and brain-fag. Soc Sci Med 1985; 21:197–203. [51] Weisman MA, Gray JJ, Mosimann JE, Ahrens AH. Cultural expectations of thinness in women: An update. Int J Eating Disord 1992;11:85-9. [52] Nasser M, Katzman MA, Gordon RA. Eating Disorders and Cultures in Transition. London: Brunner-Routledge, 2001 [53] Hoek HW, Van Harten PN, Hermans KM, Katzman MA, Matroos GE, Susser ES. The incidence of anorexia Nervosa in Curacao Am J Psychiatry 2005;162:748-52 [54] DiNicola VF. Anorexia multiforme: self-starvation in historical and cultural context. Transcult Psychiatr Rev 1990;27;245-86. [55] Nichter M. Idioms of distress: Alternative expression of psychosocial distress: A case study from India. Cult Med Psychiatry 1981:5A:379-408 [56] Witztum E, Goodman Y. Narrative construction of distress and therapy: A model based on work with Ultra-Orthodox Jews. Transcult Psychiatry 1999;36:403-36. [57] Hollan D. Self systems, cultural idioms of distress, and the psycho-bodily consequences of childhood suffering. Transcult Psychiatry 2004; 41:62-79. [58] Keyes CLM, Ryff CD. Somatization and mental health: A comparative study of the idiom of distress hypothesis. Soc Sci Med 2003;57:1833-45 [59] Greenberg D, Stravynski A, Bilu Y. Social phobia in ultra-orthodox Jewish males: Culturebound syndrome or virtue? Ment Health Relig Culture. 2004;7:289-305 [60] Morgan JF, Marsden P, Lacey JH. “Spiritual starvation”. A case series concerning Christianity and eating disorders. Int J Eating Disord 2000;28:476–80. [61] Lee S. How abnormal is the desire for slimness? A survey of eating attitudes and behaviors among Chinese undergraduates in Hong Kong. Psychol Med 1993;23:437–51.
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[62] Eddy KT, Dorer DJ, Franko DL, Tahilani K, Thompson-Brenner H, Herzog DB. Diagnostic crossover in anorexia nervosa and bulimia nervosa: Implications for DSM-V. Am J Psychiatry. 2008;165:245-50. [63] Kaye W, Strober M, Jimerson D. The neurobiology of eating disorders. In: Charney DS and Nestler EJ. The neurobiology of mental illness. New York: Oxford Press, 2004:1112-28.
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In: Understanding Eating Disorders Editors: Yael Latzer, Joav Merrick, Daniel Stein
ISBN 978-1-61728-298-0 © 2011 Nova Science Publishers, Inc.
Chapter 5
Eating Disorders: Global Marker of Change Melanie A. Katzman7, PhD
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Weill Cornell Medical Center, New York, United States of America Eating disorders can be viewed as an individual pathology revealing personal distress or more contextually as a signal of dis-order as a shifting environment calls for new mechanisms to cope with and communicate social discomfort. Contemporary narratives assert that many anorexic women are waif warriors writing a social history with their bodies, which are at once an extreme, distorted vision of beauty and a living example of social ills. This chapter will trace the evolution of cultural explanations for disordered eating-- reviewing the interface of the individual and the environment. It will then explore gendered and western oriented explanations. The chapter will also discuss global changes, supermarket and online multiculturalism and will conclude with some ideas for intervention beyond the usual disciplines of academia and mental health.
Introduction Eating disorders can be viewed as an individual pathology revealing personal distress or more contextually as a signal of dis-order as a shifting environment calls for new mechanisms to cope with and communicate social discomfort. Contemporary narratives assert that many anorexic women are waif warriors writing a social history with their bodies, which are at once an extreme, distorted vision of beauty and a living example of social ills (1). In the 19th century, cholera, a medical problem, exposed problems with rapid urbanization such as poor sanitation and limited public health services. The response to the epidemic revealed divisions of class and race, while also acting as a key impetus for greater social responsibility towards the disadvantaged (2). Encapsulated in the ”disease” of eating 7 Correspondence: Melanie A Katzman, PhD, 10 East 78th Street, Suite 4A, New York, NY 10075 United States. E-mail: [email protected].
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disorders are the 20th and early 21st century issues of identity, gender politics and the prospect of profits from marketing unobtainable ideals. This chapter will trace the evolution of cultural explanations for disordered eating, reviewing the interface of the individual and the environment. It will then explore gendered and western oriented explanations. The chapter will also discuss global changes, supermarket and online multiculturalism and will conclude with some ideas for intervention beyond the usual disciplines of academia and mental health.
Interface between individual and environment Self-starvation: The psychological predicament
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The embodiment of the psyche in human form and the dialectic of this body with its environment have been central to all causal theories of eating disorders long before the study of socio cultural influences became the vogue. In fact, early psychodynamic descriptions of the anorexic syndrome did not ignore the importance of placing the phenomenon within the context of the individual's environment. Initially psychodynamic attention was understandably focused on the contribution of the dysfunctional family as a microcosmic environment. As early as the 1800's authors remarked upon the importance of "placing in parallel the morbid condition of the patient and the preoccupation of those who surround her. The moral medium amid which the patient lives, exercises and influences would be regrettable to overlook or misunderstand" (3). From a psychoanalytic perspective, the anorexic disorder was considered an unusual variation on the neurotic theme and its historical relationship to hysteria is well established in the literature (4). Anorexia nervosa remained fairly inconspicuous and only gained prominence in recent decades when it moved from being a mere 'manifestation of neurosis’ to a specific neurotic syndrome in its own right (5).
Self-starvation: Specific neurosis reactive to the cult of thinness The specific diagnostic status acquired by anorexia nervosa has been attributed to a raise in incidence, an increase that is debatably one of perception, detection, or real presentation change. However, several publications have documented an increase over the past fifty years in western nations (6). While hysteria was commonly thought to be the product of a sexually repressive environment, anorexic thinness began to be viewed as responding to new environmental demands that promoted the desirability of thinness (7). In the second half of the 20th century, a cultural shift towards a "thin ideal" was noted in art, fashion and media advertisements and seemed to have been easily endorsed by women, the common sufferers of the disorder. The pursuit of thinness had metaphorical connotations, which meant a lot more than thinness, such as a pursuit of beauty, attractiveness, health and achievement (7).
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Self-starvation and eating disorders: The continuum hypothesis
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The growing obsession with thinness was considered responsible for pervasive dieting behavior, which in turn was linked closely to the full anorexic syndrome. This experience, said Crisp (8) "Is wide-spread amongst the female adolescent population and although it becomes very intense in the anorectic to be, it would not appear to be qualitatively different at this stage from the more universal experience" (8). The observation that the morbid phenomenon of extreme thinness does in fact blur and merge with what is considered to be normal or culturally acceptable, such as the practice of dieting, formed the basis of the continuum hypothesis. In other words dieting falls at one end of the spectrum and the extreme forms of disordered eating at the other end with a number of weight reducing behaviors of variable intensities in between. The "continuum" theory of severity was confirmed in a number of community studies which showed the presence of sub clinical forms in normal student populations (9-13). In fact the sub clinical forms were generally estimated to be five times more common than the full-blown syndromes (14). The epidemiological impression that bulimia and bulimic behaviors appear to be far more prevalent in the community than the anorexic syndrome raised the possibility that the nature of both conditions, despite psychopathological similarities, are different. In the case of anorexia, the cardinal feature is restraint, which requires a strong internal drive, however the bulimic disorder may be more responsive to external environmental reinforces (15), even suggesting that bulimia may result from a set of “socially contagious" behaviors. Hoek et al (16) in their cross cultural work in Curacao have suggested that anorexia may be more epidemiologically stable while bulimia may increase with growing urbanization. Whether one looked at anorexia or bulimia over time, one thing was consistent – more women than men were demonstrating clinical and sub clinical concerns with weight and diet. Why should this be an issue specific to women and why at this point in history?
Eating disorders: gender specific? The 'why woman' question in the early eighties was framed as a feminist issue although as writers later in the 20th century revealed, the question of gender is one that impacts all professionals working in the field of eating disorders (17). Women's susceptibility to eating problems and the pursuit of a thin ideal has been viewed as: a rebellion against the adult female form and all that is implied with being a woman in today's society; an effort to obtain an androgynous physique at a time when men are still viewed as more powerful; as a means of demonstrating mastery and control; and of course a realistic adaptation to the availability of fashionable clothes and a susceptibility to the 'culture of health' in which leanness is associated with longevity. Commenting on the role of gender and eating disorders, Katzman (18) suggested that it was access to power that put one at risk rather than one’s chromosomal make up -- it just so happened that more women had obstacles to independence and achievement!! Littlewood (19) noted that looking cross culturally it was in fact the ability for self-determination that differentiated male and female eating problems. Animal analogues of elective starvation are
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consistent with data from human suffers in suggesting that submissive behavior and social defeat are implicated in the onset of anorexia nervosa (20).
Eating disorders: culture specific The expansion of the gender debate to include a study of social and political impacts on behavior enabled the field to consider the importance of not only western but all cultures. While the early eighties and nineties enjoyed a fascination with the western woman's predicament, and the eastern woman's 'protection' from eating distress (by virtue of clearly defined social roles and in some cases an acceptance of plumpness as a sign of success), further sophistication of these models revealed not only gender myopia but a cultural visual restriction as well. No one was immune to eating problems. Perhaps our diagnostic criteria and theoretical lenses had been somewhat selective. Although eating disorders in the eighties and early nineties were considered culture bound, (7) by the end of the nineties, with increasing data from the east, the limitations of seeing the problem as exclusive to "one culture" and "one sex", namely western culture and western women were apparent (21).
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Eating disorders: a worldwide concern Nasser (22) conducted an extensive review of the published studies of eating disorders in the east and west and found few national or societal boundaries that contained the growing detection of eating problems, albeit sometimes with a twist. For example, in the east, the work of Sing Lee and colleagues (23) consistently demonstrated anorexia in the absence of a fear of fat. These findings along with discoveries of eating issues in unexpected places like the Middle East challenge us not to ask 'if' problems exist but 'how'? (24) For example how do eating disorders present themselves and how do we understand and treat these problems and how can we be inspired in our etiological models by data that may challenge our traditional notions of why people choose to alter their bodies or diets in times of distress? The emergence of eating pathology in the majority of societies was initially linked to an exposure to and identification with western cultural norms in relation to weight and shape preferences -- especially for women. The media was considered the main culprit in disseminating these values and in homogenizing public perceptions. The pressure to "remake the body" to match newly unified global aesthetic ideals was seen to operate through international advertising and worldwide satellite networks. While certainly plausible, the question remains why would women be so susceptible to media programming and what does the globalization in the market place reflect in terms or women's roles that might impact on the development of eating disorders? In an analysis of "feminism across cultures", Nasser (22) pointed to the fact that feminist movements similar to those in the West also arose in other non-western societies which resulted in questioning and debating traditional gender roles. The majority of non-western women have significantly changed their position, with increasing numbers of them being highly educated and working outside the family. This meant that the pressures that are hypothesized to increase western women's propensity to eating disorders are increasingly
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shared by all women of different cultures and societies. Katzman et al. (25) illustrated in their analyses of ‘anorexia’ in Curacao, that the development of eating disorders is likely linked with the exposure to ‘possibility’ and the frustrations of not being able to achieve one’s ideals. So yet again the opening of a theoretical frontier brings with it as many questions as it does inspirations. For example, does “westernization" only mean “image- identification" or is there more to it? How would the issue of westernization relate to other issues such as urbanization, modernization and economic globalization? And even if we tried to break down the concept into constituent elements, would that be sufficient to explain a universal preoccupation with weight? Or does "weight" mean perhaps much more than mere body regulation? Is the quest for refashioning the body a quest for refashioning the self (i.e. remaking of a new identity) in an effort to negotiate the impact of a volatile and constantly changing culture?
Evolution of Eating Psychopathology
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Body regulation and identity In some of the early descriptions of the anorexic syndrome one can find fashion driven explanations for the role of environment in the development of eating psychopathology. Bruch (26) indicates that the environment of the family with its pathological interactions could indeed create an "identity deficit". Within this remit, the anorexic symptomatology serves as a defense against feelings of "powerlessness", and the act of food refusal becomes symbolic of a strive towards autonomy and mastery over one's self as well as others. The failure of individuality or incomplete identity described in Bruch's analysis was later applied beyond the boundaries of the domestic circle, to include an individual struggle for autonomy against social pressures in a much wider context. The feminist text clearly put the notion of identity at center stage within the anorexic struggle. Self-starvation becomes a way for women to develop an identity as a person in the absence of real control or power in other areas of their life (27). Historically the displacement of the locus of power to the body was noted to occur during periods of cultural transition particularly at times when "identity definition or redefinition” is called for. Under these conditions, morbid forms of bodily control are seen as symptomatic of the “transition in culture" and not the "culture" per se (22). The notion of the social predicament was therefore advanced as a possible explanatory model for eating disorders. Taylor (28) describes predicaments as “painful social situations or circumstances, complex, unstable, morally charged and varying in their import in time and place". Perhaps by applying the social predicament model to bulimia and anorexia we can better understand the diversity of cultural experiences and hopefully decode the metaphors contained within the symptoms. However, even the socio-cultural models of the late twentieth century remained overly focused on weight and media control in an effort to capture how existing social structures could exercise a quantitative and qualitative influence on individual psyches. As a result,
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there are a number of questions that clearly illustrate the limitations of our current approach to understanding the nature of these disorders vis-à-vis culture: • •
• • • •
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•
Given that Western Europe and Northern America constitute what is commonly known as the West, why should the rates of eating morbidity be higher in the American society than in central Europe? (29) Even within Europe itself, why there should there be any differences between east and west Europe, given their shared European heritage (except for a very brief historical period of fifty years or so)? And how true is the claim that eating disorders began to appear in Eastern Europe only after the decline of communism? (30) What could possibly be the reasons behind the reported 800% increase of eating morbidity in the Kibbutz in the past 25 years? (31) Why should there be any differences at all in the rates of eating disorders between the north and the south of Italy—or any culture within a culture for that matter? (32) What is the explanation for differences in the rates of anorexia nervosa between urban and rural Japan or indeed the reasons behind their reported 100% increase in only a 5-year period? (33) What significance could be attached to the apparent rise of eating disorders among black South Africans girls after the fall of the Apartheid regime? (34) Why is anorexic self-starvation in Hong Kong not associated with a fear of fatness, while in the west such fear is considered pathognomonic? (35-36)
Well the skeptic might just say that these idiosyncrasies prove the unreliability of cultural research, (for example the use of unreliable self report measures in the absence of clinical interview and the failure to involve random and community samples over time), it would be too simplistic to dismiss them as mere artifacts. In order to begin to understand the reasons that may lie behind such variabilities, one needs to have a deeper understanding of the type of culture we live in, which appears to be multiple fragments within a globally "homogenous/homogenized entity". There are therefore several "contradictory" elements within this apparent modern uniformity and the tension at the moment is therefore likely to be between the "one" and the "multiple."
A Gastronomically and Technologically Flattened World Shaping appetites: Gastronomic diversity and standard McDonaldism One notable aspect of modernizing societies is their attempt to embrace different cultural/ethnic elements within a unified whole, to enable culture to be one and multiple at the same time. This is achieved through what is now commonly referred to as "supermarket multiculturalism" i.e. the exposure of the west to other cultures through their cuisine, or other exotic pastiches and vice versa. Foreign ingredients and ready-made meals have found their way to supermarket shelves and there is a clear proliferation of different foreign restaurants in any major city, from the Chinese and Italian to Indian and Thai, etc.
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Many countries in the non-western world are undergoing major changes in their dietary habits through the introduction of Western fast food chains selling items such as beef burgers and fried chicken. The impact of these restaurants on the quality and choice of food available was initially studied in highly urbanized western society (37) and was offered as one of the possible reasons behind the different rates of eating disorders between Europe and the USA. Several studies from non-western societies have extended this hypothesis and now point to a possible link between the changes in traditional diet and the inevitable impact on population weight and shape secondary to the increased fat content of one’s diet. These dietary changes could lead to a rise in the rates of obesity worldwide and may in fact prompt greater weight consciousness and possible eating pathology (22). Pollan (38) illustrates the tensions between subsidized corn farming, the resulting corn surplus and the increase in grain in fast food. Fast meals are now ‘supersized’ increasing profit while increasing the risk of obesity. As national profit increases so do public health risks. Another factor contributing to rates of obesity, apart from the ongoing changes in the nature of food consumption and production, is the shifting of meal times such that the main meal is now consumed in the evening and often not in the presence of others. Later hours at work or school and the demand for longer uninterrupted hours are some of the consequences of increased urbanization and modernization. The need for faster, pre-packaged food to keep pace with changing work demands has impacted family roles and notional habits. Given dietary changes and reduced physical activity it is not surprising that a governmental summit held in London in April 2000 concluded that the average norm for population weight in the UK had significantly increased in the past two decades -- particularly for women. As a reflection of this, the popular Marks and Spenser stores began using a size sixteen model to promote their clothes lines! Obesity is also a recognized problem in the States, where nearly 30% of the population is classified as obese .The relationship between obesity and the eating patterns of anorexia and bulimia are well documented. (7) It is also well known that people tend to overeat at times of emotional tension -- "obesity has an important positive function, and it is a compensatory mechanism in a frustrating and stressful life" (39).
Food abundance and food shortage: Economic forces With an increase in economic freedom in various countries has come a departure from state supported privileges. While potentially providing greater opportunity for all, there have in fact been greater differentials of wealth and poverty between countries and within the same country. A market economy is based on the principle of cost-effectiveness, which heightens competition as well as standardization as increases in productivity are sought. A deregulated economy is built on the primacy of individual choice which can produce increased social inequalities as well as social isolation, and is likely associated with increased commercialization and material aspirations (22). Several clinicians and researchers from Eastern Europe have suggested that the increase in commercialism and changing gender roles coupled with the depletion of state offered benefits (such as education, employment and health care) may result in the commodification of the human body and modifications to its form to fit with global standardizations of beauty, marketability and adaptability (40). This in turn may make women more susceptible to eating
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problems as they may be forced to not only adapt their bodies to a new form but form their identities to a new role. Hence their bodies may become placards for social distress and transition.
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Cable and online cultures Subtle (and not so subtle) social revolutions are not the only shifts that impact bodily expression. The deregulation of markets, family life and meal structure are all potential risk factors for personal pathology, but an additional destabilizing force emerges from technological revolutions. One must consider the role of online cultures in increasing individuals’ alienation. Is it possible that the deregulated media deregulates the relationship between the individual and society? Several authors such as Morley and Robins (41) have attempted to explore this concept concluding that changes in computer culture have meant a change in how we relate to our own nation as a geographic entity. As one types and taps into a shared global environment they may in fact be traveling beyond their familiar nexus to ideas and fashions never considered by their homes or home country. The inherent advantages of potentially unlimited choice are pitted against the need to negotiate these choices, to learn how to reformulate an identity amidst an influx of visual information and images. Identities in the new media order need to be similar and different at the same time! Individual personalized cultures inevitably arise within the context of the uniform and the universal. This means that the act of transmitting image/information shifts from broadcasting to narrowcasting with special programming aimed at specific target and differentiated audiences. How does one fit in and where? How does one connect to others and how? Electronic connections may provide a new way of achieving connectedness. Linked by computer technology, women may be able to overcome their social and political isolation and gain new insights into formulas for success and survival. Nasser and Katzman along with others (42) have also suggested a shift in emphasis towards competencies rather than pathology in prevention and treatment strategies. While the notion of working with peoples' strength is central to motivational approaches to treatment (43), how to creatively deploy potential resources and make healthy links between people has not yet been fully leveraged and in some instances has been exploited to individual detriment in a deregulated internet support era. For example, websites that celebrate anorexic behaviors (called pro-ana as in pro anorexia) may operate against healthy growth and in fact create a forum for those looking to learn new weight reduction techniques rather than methods for recovery.
Conceptualizing eating issues as culture change In earlier works Katzman (44) and Katzman and Lee (36) have argued that eating disorders may be precipitated by problems with transition, dislocation, and oppression that produce solutions in manipulations of weight, diet and food. As one examines the movement of eating disorders from individual neurosis to cultural monikers of distress, it becomes increasing
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important to identify ways of operationalizing treatment and prevention strategies. By organizing our research and clinical questions around ways of assisting women in self determination, control and connection rather than simply documenting media and weight insults we may be able to progress beyond the limitations of our current strategies and provide alternatives for women struggling with eating disorders as an 'answer' to complex personal social and personal problems. As the position of individuals, particularly women, is changed and challenged internationally, it may become increasingly important to work toward social change not merely symptom change, to look not only at individual cosmetic concerns but responsible cultural consciousness. This may require a broad examination of social morbidity and a further examination of the effects that subordinate positions may have on individual psyches (45). A new generation of business leaders appears to have moral compasses with a gravitational pull towards achieving greater social impact. Corporate social responsibility programs are becoming a part of the business culture -- dedicating intellectual and monetary capital to community development and the alleviation of societal ills (46). How can the interest in social action and contributions emerging from other fields be harnessed to respond to the precipitants of disordered eating? Today’s media presents the war on terrorism, the war for resources and of course the war on fat. This very aggressive language marshals attention and demands a response. How do we parlay the attention into positive action? Perhaps there are creative ways to partner with people beyond our discipline to explore alternatives that are healthy and if necessary profitable too. The feminist social/cultural analysis has been both inclusive of various disciplines while remaining handicapped in the ability to influence finance and politics to a meaningful extent. Much of our scientific research looks at MRI’s not ROI’s (returns on investment). We talk of power and recognize that it is gendered; but hierarchy is not merely pink or blue. The better able we are to analyze and respond to the economic realities that inform the marketing of mental distress, the better able we will be to craft creative, healthy solutions. Our challenge as a field is how to communicate outside of academia. What are the words and arguments that will capture the attention of business leaders and social entrepreneurs in addition to our traditional granting agencies and policy makers? Our formulizations and suggestions cannot make sense only to ourselves, and we can surely benefit from the intellectual prowess of other applied fields (46). Bill Gates, the founder of Microsoft, says he is ‘reordering his priorities’ to work on his $29 billion foundation, focusing primarily on global health. The investment bank Goldman Sachs recently announced that it will invest $100 million over the next five years in providing 10,000 women in developing economies with business and management education -- a decision based on their research indicating that investing in women in the developing world is most likely going to yield the greatest social return. Is this not the same group that we would identify as at risk for eating disorders because of the possibility for greatest disparity between what is possible and what is likely? If we can view eating disorders as a marker of cultural transition then our challenge will be to empower and support individuals as they evolve in new roles, to move beyond diagnosing people to preventing eating disorders through social initiatives that profit all members of a society.
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Malson H, Burns M, eds. Critical feminist approaches to eating dis/orders. Psychology Press. Routledge; in press. Evans RJ. Epidemics and revolutions: Cholera in nineteenth century Europe. Past Present 1988;120(1):123-46. LaSegue C. De l’anorexie hysterique. Arch Gen de Med 1873:385. [French] Silverstein B, Perlick D. The cost of competence: Why inequality causes depression, eating disorders and illness in women. Oxford: Oxford Univ Press; 1995. Russell GFM. Anorexia nervosa: Its identity as an illness and its treatment. In: HardingPrice J, ed. Modern psychological medicine. Vol 2. London: Butterworths, 1970:131-64. Hoek H, van Harten P, Hermans K, Katzman MA, Matroos GE, Susser ES. The incidence of anorexia nervosa on Curacao. Am J Psychol 2003;162:728-52. Swartz L. Anorexia nervosa as a culture-bound syndrome. Soc Sci Med 1985;20:725-30. Crisp AH. Anorexia nervosa: Let me be. London: Plenum Press, 1980. Button EJ, Whitehouse A. Subclinical anorexia nervosa. Psychol Med 1981;11:509-16. Szmukler GI, Russell GF. Diabetes mellitus, anorexia nervosa and bulimia. Br J Psychol 1983;142:305-8. Mann AH, Wakeling, A, Wood, K, Monck, E, Dobbs, R, Szmukler, G. Screening for abnormal eating attitudes and psychiatric morbidity in an unselected population of 15-yearold schoolgirls. Psychol Med 1983;13(3):573–80. Johnson-Sabine E, Wood K, Patton GC, Mann A, Wakeling A. Abnormal eating attitudes in London schoolgirls: A prospective epidemiological study: Factors associated with abnormal response on screening questionnaires. Psychol Med 1988;18:615-22. Katzman MA, Wolchik SA, Braver S. The prevalence of bulimia and binge eating in a college sample. J Cons Clin Psychol 1984;3(3):53-61. Dancyger IF, Garfinkel PE. The relationship of partial syndrome eating disorders to anorexia nervosa and bulimia nervosa. Psychol Med 1995;25(5):1019-25. Palmer RL. Culture, constitution, motivation and the mysterious rise of bulimia nervosa. Eur Eat Disord Rev 1998;6:81-4. Hoek, HW, Treasure JL, Katzman MA, eds. Neurobiology in the treatment of eating disorders. New York: John Wiley, 1998. Katzman MA, Waller G. Implications of therapist gender in the treatment of eating disorders: Daring to ask the questions. In Vandereycken W, editor. The burden of the therapist. London: Athone Press, 1998. Katzman MA. Getting the difference right: It is power not gender that matters. Eur Eat Disord 1997;5(20):71-4. Littlewood R. From categories to contexts: A decade of the ‘new cross cultural psychiatry’. Br J Psychol 1990;156:308-27. Troop NA, Allan S, Treasure JL, Katzman MA. Social comparison and submissive behavior in eating disorder patients. Psychol Psychother 2003;76(3):237-49. Witztum E, Latzer Y, Stein S. Anorexia nervosa and bulimia nervosa as idioms of distress: From the historical background to current formulations. Int J Child Adolesc Health 2008;1(4):283-94. Nasser M. Culture and weight consciousness. London: Routledge, 1997
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[23] Lee S, Ho TP, Hsu LKG. Fat phobic and non-fat phobic anorexia nervosa: A comparative study of 70 Chinese patients in Hong Kong. Psychol Med 1993;23:999-1017. [24] Latzer Y, Witzum E, Stein D. Eating disorders and disordered eating in Israel: An updated review. Eur Eat Disord 2008;16:1-14. [25] Katzman MA, Hermans K, Hoeken D, Hoek H. Not your typical woman: Anorexia nervosa is reported only in subcultures in Curacao. Culture Med Psychol 2004;28:463-92. [26] Bruch H. Anorexia nervosa: Therapy and theory. Am J Psychol 1982;139:12. [27] Orbach S. Hunger strike: The anorexic struggle as a metaphor for our age. New York: Norton, 1986. [28] Taylor D. The sick child’s predicament. Aust NZ J Psychol 1985;19:130-7. [29] Neumärker U, Oudeck U, Neumärker KJ, Vollrath M, Steinhausen HC. Eating attitudes among adolescent anorexia nervosa patients and normal subjects in former West and East Berlin: A transcultural comparison. Int J Eat Disord 1992;12(3):281-9. [30] Rathner G, Tury F, Szabo P, Geyer M, Rumpold G, Forgacs A, et al. Prevalence of eating disorders and minor psychiatric morbidity in central Europe before the political changes of 1989: A cross-cultural study. Psychol Med 1995;25:1027-35. [31] Kaffman M, Sadeh T. Anorexia nervosa in the kibbutz: Factors influencing the development of monoideistic fixation. Int J Eat Disord 1989;8(1):33-53. [32] Ruggiero GM. Eating disorders in the Mediterranean area. New York: Nova Sci, 2003. [33] Ohzeki T, Hanaki K, Motozumi H, Ishitani N, Matsuda-Ohtahara H, Sunaguchi M, et al. Prevalence of obesity, leanness and anorexia nervosa in Japanese boys and girls aged 12-14 years. Ann Nutr Metabol 1990;34:208-12. [34] Le Grange D, Louw J, Breen A, Katzman MA. The meaning of ‘self-starvation’ in impoverished black adolescents in South Africa. Culture Med Psychol 2004;28(4):439-61. [35] Lee S. Self-starvation in context: Towards a culturally sensitive understanding of anorexia nervosa. Soc Sci Med 1995;41:25-36. [36] Katzman MA, Lee S. Beyond body image: The integration of feminist and transcultural theories in understanding self-starvation. Int J Eat Disord 1997;22:385-94. [37] Nassar M, Katzman MA. Socio-cultural theories of eating disorders: An evolution in thinking. In Dare C, Treasure J, Schmidt U, van Furth E, editors. Revised handbook of eating disorders. West Sussex, England: Wiley, 2003:139-50. [38] Pollan M. The omnivore’s dilemma: A natural history of four meals. New York: Penguin, 2006. [39] Bruch H. Eating disorders. London: Routledge Kegan, 1974 [40] Nasser M, Katzman MA, Gordon R, Eating disorders and cultures in transition. London: Routledge, 2001 [41] Morley D, Robins K. Spaces of identity, blobal media, electronic landscapes and cultural boundaries. London: Routledge, 1997. [42] Nasser M, Katzman MA. Transcultural perspectives inform prevention. In: Piran N, Levine M, Steiner-Adair C, eds. Preventing eating disorders: A handbook of interventions and special challenges. New York: Brunner Mazel, 1999:26-43. [43] Treasure J, Schmidt U. In Arkowitz H, Westra H, Miller W, Rollnick S, eds. Eating disorders: Clinical applications of motivational interviewing. New York:Guilford, in press [44] Katzman MA. Feminist approaches to eating disorders: Placing the issues in context. In: De Risio S, Bria P, Ciocca A. Psychotherapeutic issues on eating disorders: Models, methods and results. Rome: Societa Editrice Univ, 1998. [45] Connan F, Katzman MA, Treasure J. A neurodevelopmental model for eating disorders. Br Assoc Behav Cogn Ther Meet, Bristol, England, 1999.
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[46] Katzman MA. Preface to Malson H, Burns M. Critical feminist approaches to eating dis/orders. London: Psychol Press Routledge, in press.
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In: Understanding Eating Disorders Editors: Yael Latzer, Joav Merrick, Daniel Stein
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Chapter 6
Eating-related Psychopathology in Israel: Nationwide Perspectives and Focusing on Specific Populations
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Yael Latzer8, DSc1, Eliezer Witztum, MD2 and Daniel Stein, MD3 In this chapter we present the most updated findings with respect to eating disorders and disordered eating in Israel. Our chapter highlights that the frequency of maladaptive eating among female and male Israeli Jewish adolescents is higher in comparison to many other Westernized countries. Among different Jewish sub-populations, Kibbutz women have been found until recently to show higher rates of disordered eating in comparison to other Israeli samples. Recent studies show no such difference. No clear-cut findings emerge with respect to the influence of immigration and degree of Jewish religious affliction on the occurrence of disordered eating. By contrast, disordered eating is less prevalent in Israelis of Arab decent compared with the Israeli Jews. Moreover, diverse Israeli-Arab groups show different rates of disordered eating. We discuss the high rate of disordered eating in Israeli youth in light of Israel being a culture in transition that is constantly exposed to the risk of terrorism. The changes in the rates of disordered eating in the Kibbutzim are discussed in light of the dramatic societal changes occurring in these communities within a relatively brief period of time. The low rates of disordered eating in Israeli-Arabs reflect the traditional nonWesternized characteristics of their society, whereas the differences between diverse Arab sub-populations depend upon the degree of exposure to Westernized influences and the presence of conflicts between modern and traditional values. 8 Correspondence: Yael Latzer, DSc, Eating Disorders Clinic Rambam Medical Center, Haifa, Israel University of Haifa, Faculty of Social Welfare and Health Sciences, Mount Carmel, Haifa, 31905 Israel. E-mail: [email protected]. 1 Eating Disorders Clinic, Psychiatry Division, Rambam Medical Center and the School of Social Work, Haifa University, Haifa 2 Psychiatry Division, Faculty of Health Sciences, Ben Gurion University of the Negev, Beer Sheva 3 Pediatric Psychosomatic Department, Safra Children’s Hospital, Chaim Sheba Medical Center, Tel Hashomer and Sackler Faculty of Medicine, Tel Aviv University,Tel Aviv, Israel
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Introduction Traditionally, the development of eating disorders (EDs), including anorexia nervosa (AN) (1) and bulimia nervosa (BN) (2), has been related to a host of socio-cultural parameters. Both disorders have been conceptualised until recently as representing culture-dependent syndromes, namely as syndromes that cannot be understood separated from their cultural context (1), and that are restricted to a limited number of cultures by virtue of psychosocial factors (2,3). Recent studies cast doubt however, on the definition of AN as culturally dependent. This because the current prevalence of AN in many non-Westernised cultures is often similar to that found in Western societies, and the recent increase in its in Western countries appears to reflect greater use of treatment facilities rather than a genuine change (4). By contrast, BN is still conceived to represent a culturally dependent syndrome, as a sharp increase in the incidence of the disorder has occurred in Westernised countries in the latter half of the 20th century, and its appearance in non-Westernised cultures is still infrequent, and almost always in the context of some exposure to Western influences (4). Israel presents a unique opportunity to study the role of socio-cultural parameters in the development of EDs and disordered eating-related preoccupations and behaviours, because of the exceptional diversity of the Israeli society. Israel is a multi-cultural nation to which Jews have immigrated from a multitude of countries within an exceptionally brief period of time. Furthermore, Israeli society includes many ethnic and religious groups and has a multitude of educational systems and schools, according to the degree of religious background and the residential living style. It is anchored in ancient traditions, yet poised at the apex of cuttingedge technology. The aim of the present chapter is to analyze the current state of art concerning eating disorders (EDs) and disordered eating behaviours in Israel, according to an extensive literature review by means of the PUBMED, PSYCHLIT, PSYCHINFO and ERIC, as well as relevant Hebrew references. Disordered eating is a broad construct, including subclinical EDs [eating disorders not otherwise specified (EDNOS)] (5), as well as aberrant preoccupations, attitudes and behaviours, related to shape, weight, body image, and food that do not reach the levels of EDNOS. Unlike full-blown EDs, disordered eating is not a psychiatric diagnosis achieved with accepted diagnostic criteria (e.g., the DSM-IV (6)), but rather represents a broad spectrum of subsyndromal features of EDs. This term is often used in the description of maladaptive ED-related features (7-10) The first part will focus on EDs and disordered eating behaviours and attitudes within the larger Israeli society. We then turn to the association between socio-cultural issues and disordered eating in diverse Israeli sub-populations. The article places a special emphasis on reviewing disordered eating among new immigrants, the Kibbutz population, and the IsraeliArab population. Additionally, it considers the influence of Jewish religion and its observance level and religious affiliation on EDs and disordered eating. In the last part of the article we discuss the disordered eating phenomena in Israel as a reflection of the Israeli culture. We relate in particular to socio-cultural influences on disordered eating of the Israeli society being a culture in transition that is constantly exposed to traumatic events, focusing additionally on the association between the diversity of exposure of different Israeli socio-
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cultural subgroups to Westernised ideals and the occurrence of disordered eating in these populations.
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Full blown and subsyndromal eating disorders Only a few community-based studies have been performed to assess the prevalence of EDs in Israel. Scheinberg (11) surveyed 1112 Israeli female soldiers between the ages 18-20, and found 2.4% with a subsyndromal ED, 0.2% with AN, and 0.5% BN. However, the results of this study cannot be generalized, as it includes only specific age groups and specific populations (not all Israeli female adolescents are recruited to the army). Mitrany et al (12) surveyed all Israeli ED treatment facilities (there were 24 such inpatient and ambulatory centres) over a five-year period (1989-1993). Of the 632 new cases identified (almost all were females, and most were adolescents), 60% were diagnosed with AN, 17% with BN, 4% with AN and BN, and 20% with EDNOS. From theses results, the authors extrapolated that the mean annual incidence for all EDs among Jewish Israeli female adolescents was 48.8 per 100,000, for AN 29.0/100000 and for BN 8.6/100000. As the authors themselves acknowledged, the results of this study, which were markedly different from most epidemiological data (4,13) were confounded by serious methodological problems, casting doubts about their validity. Most likely, these figures represented an underestimation of the actual incidence due to incomplete data accrual. Stein et al (14-16) evaluated the rate of subsyndromal restrictive and bingeing/purging type EDs in a series of female 10-12th graders and army recruits according to the combination of a pathological EAT score (>22 points) and the presence of some of the DSMIV criteria for AN or BN. Between 12-21% of the subjects were identified as having a subdyndromal restrictive type ED, and 8-19% were identified as having a subdyndromal bingeing/purging type ED. Individuals with subsyndromal EDs had greater rates of core EDrelated traits (e.g., obsessionality or impulsivity) than non-ED participants, supporting, the validity of this distinction. The authors attribute the relatively high rates of subsyndromal EDs in their studies (most studies report rates in the range of 5-15% e.g., Shisslak et al, 1995) to the use of broad ED definitions (e.g., they included patients who binged or purged only sporadically) and self-report questionnaires, rather than structured clinical interviews (17). Another analysis was carried out by Latzer and Gilat (18,19) on all calls [19,776] received by the only Israeli crisis hotline (ERAN) over a period of four years, from individuals suffering from EDs. The results revealed a steady increase in the rate of EDs among female adolescent callers, from 1.7% in 1994 to 3.1% in 1997, with EDs being the second most frequently identified problem among this group of callers. About one-third of the total ED-related callers could be identified as AN, another third as BN, about a quarter as binge eating disorder (BED), and the rest as ED-NOS. The authors relate the over representation of AN among the hotline callers to the inclination of AN patients to refrain from treatment, making it more likely that they might turn to a crisis hotline when distressed (20).
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Eating-related attitudes
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Eating attitudes among Israeli elementary school children In recent years, combined with the increase in the incidence of EDs, average age at onset has tended tend to decrease (13,21). Extensive dieting, fear of becoming overweight, and bingeeating have been identified in girls as early nine years old (22). The early appearance of preoccupation with weight and dieting is considered an important risk factor for a later development of maladaptive eating behaviours (10,23). As it is important to identify children at risk as early as possible, Sasson et al (24) replicated Maloney et al’s (22) study with Israeli children. The researchers used the Ch-EAT [a modification of the Eating attitudes Test-26 (EAT-26) for children] to examine eating attitudes and behaviours among urban students (boys and girls) of grades 3-6 (elementary school) and 7-11 (high school) in Jerusalem, Israel. This Israeli study substantiated the findings of Maloney et al (22) within an American sample, namely that dieting attitudes and behaviours can begin very early, clearly prior to adolescence. An impressive percentage of students throughout the surveyed age range revealed preoccupation with food, thinness, and weight loss: 54% expressed a desire to lose weight, and 41.6% showed behaviours geared towards losing weight. Girls exhibited a significantly greater tendency than boys to want to become thin, to attempt to lose weight, and to be preoccupied with dieting. This eating-related preoccupation among girls increased with age from the eighth grade onwards, in sharp contrast to the boys’ relatively low preoccupation that decreased with age. Interestingly, this Israeli sample of preadolescent girls expressed a greater wish for thinness and engagement in dieting behaviours than preadolescent girls in other modernized Western countries (25). Halevy and Halevy (26) examined cognitive, socio-cultural, and behavioural components of eating disturbances in 251 boys and 280 girls from three schools in Jerusalem (5th-8th grade). Girls scored consistently higher than boys on all weight-control behaviours. Greater frequency and severity of discontent with one’s own body and of other pathological eatingrelated attitudes and behaviours were positively associated with “social age.” Seventh graders scored significantly higher than sixth graders, suggesting the 7th grade to be a period of increased vulnerability. In another study conducted by Flaisher-Kellner (27) among 136 children of grades 2-5 (mean age 9.6) from four primary schools in Haifa and 98 of their parents, the students were presented with different age-matched female figures (28). Significantly more girls than boys expressed dissatisfaction with their body shape and felt heavier than a socially ideal figure. Additionally, the higher the body mass index (BMI) of the students, the more dissatisfied were they with their physical appearance.
Eating disorder among Israeli adolescents Between 60-80% of Israeli female adolescents are dissatisfied with their weight and shape, although the vast majority of these youngsters are of normal or even low weight (14,29-31). An international study of health behaviour among schoolchildren (World Health Organization, Health Behavior in School-Aged Children-WHO-HBSC) was conducted in 28
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Westernised countries in 1994 (29), and in 44 Westernised countries in 1998 (most countries in Western and Central Europe and North America participated in one of the two studies, or both). In both studies, the frequency of dieting behaviour at the time of evaluation was the highest among Israeli Jewish adolescents compared with all other participating countries, for both girls (34.5% and 28% respectively) and boys (8.9% and 11% respectively) (29, 30). In a more recent study undertaken in 2001-2002, Israel ranked the 2nd among 33 Westernised countries, surpassed only by Denmark, with 26% of Israeli girls engaged in dieting behaviour at the time of assessment (32). It is important to note that only 6% of the respondents reported that they were dieting under professional supervision, highlighting that around a 13% of Israeli youngsters diet without such supervision. Moreover, almost 50% of all students engaged in physical activities to lose weight, 3% reported purging behaviours (vomiting and laxative use), and another 2% used diet pills (30). A study conducted by Neumark-Sztainer et al (31), which assessed eating attitudes and behaviours among Israeli adolescent females, showed that whereas only 17% were overweight, 47% reported dieting when assessed, and 74% reported dieting in the past. In another two studies assessing maladaptive eating–related behaviours (EAT-26, 1270 participants) (33) and preoccupations (Eating Disorders Inventory-2, 1316 participants) (34) in 12-18 years old Jewish Israeli girls, almost 20% were found to show pathological EAT-26 scores, with 16-18 years old girls having the highest EAT-26 and EDI-2 scores compared to the other age groups. More recent studies using the EAT-26 in Israeli adolescents have also demonstrated that around 20% of the females (and 5% of the males) interviewed had pathological EAT-26 scores (35,36) Gur et al (37) analysed the findings on the EAT-26 in all students between the ages of 1216 who were studying in the only school of a suburban upper class community during 2001. One hundred forty five of all 730 female students (20%) and 53 of all 775 male students (6.8%) had a pathological EAT-26 score. A constant rate of pathological EAT scores was found in the male students regardless of their age (6-10%), whereas among females, a significant increase was noted in 16-year old participants (29%) compared to younger populations (18-21%). Compared to participants with normal EAT-26 scores, both male and female students with pathological EAT results scored higher on all EDI-2 scales, as well as on other scales evaluating core ED features, e.g., perfectionism and selflessness (37). Interestingly, male students with pathological EAT-26 scored higher than females with pathological EAT-26 scores on all EDI-2 subscales. A recent study assessed eating behaviours with a modified SCOFF questionnaire in a national representative cross-sectional study including 2,978 Israeli schoolgirls age rang 1418 (mean age 14.7). The SCOFF is a validated screening questionnaire for detecting disordered eating behaviours in community populations. Thirty percent of the participants were found to fulfil the SCOFF criteria for disordered eating. The presence of dieting, early onset of menarche, being overweight, or obese, and suffering from constipation was found to increase the risk for positive identification with the SCOFF, whereas socio economic status, school performance, physical activities and smoking status were not contributory (38).
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Socio-cultural aspects Israel includes several types of socio-cultural residential settings, such as urban, communal village and Kibbutz frameworks. In addition, Israeli Jews differ in their level of religiosity, and there are several types of Arab sub-populations (Muslim, Christian, Druze, Bedouin, and Circassian). Unfortunately, the literature concerning possible differences in eating-related attitudes and behaviours among these populations is scarce. Apter et al. (39) assessed eating attitudes, using the EAT-26, among healthy Jewish girls in five high-schools. The highest mean EAT-26 scores were shown by the Kibbutz students (14.1±1.7), and the lowest by the students of two boarding schools (10.2±1.5), with 27.3% of the Kibbutz and 16.2% of the two boarding school students representing maladaptive eatingrelated behaviours (EAT-26 >20). Different results were obtained in another two studies that administered the EAT-26 (33) and the EDI-2 (34) to 12-18 year old Jewish girls in several educational settings in northern Israel: urban-secular, Kibbutz, and two boarding schools, one secular, and the other a religious boarding school. The secular boarding school students were found to have the most pathological EAT-26 and EDI-2 scores. These findings suggest that eating-related pathology may increase in the face of adverse conditions for growing up (most of the students of the two boarding schools were from problem families of particularly low socioeconomic background), although religiosity in itself may have, in this case, a protective influence. In contrast to Apter et al's (39) findings more than 10 years earlier, the Kibbutz students in these two studies had the lowest EAT-26 and EDI-2 scores, a finding that will be discussed in a later section of our article.
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Immigration to israel and eating disorders From 1948 to 2006, Israel experienced a few large immigration waves. The first one took place in the 1950s, bringing to Israel about one million immigrants. In the late 1980’s and early 1990’s, another massive wave immigrated to Israel from the Former Soviet Union (FSU) (around a million immigrants) and Ethiopia (close to 100,000). New immigrants currently comprise approximately 15% of the Israeli population. Similar to other countries which absorb large numbers of immigrants, economic, social, and cultural difficulties may arise in these populations as a result of the cultural gap between Israel and the countries of origin. Many studies have shown that youngsters who have immigrated to a new country are at a greater risk to develop disordered eating, or in this respect any psychiatric disturbance, in comparison to native-born young people, as a result of the heightened distress associated with immigration (40,41). Young females may be at an additional risk of developing disturbed eating if emigrating from a non-Western country such as the FSU or Ethiopia to Israel, because of their inclination to adopt the norms of the absorbing society, in this respect norms that reinforce the thin body ideal (42,43). Alternatively, disturbed eating may result from the stress associated with immigration that may bring newly arrived immigrants to use food as a means to cope with depressive symptoms associated with acculturation, or to disguise these symptoms.
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Young female immigrants may strive to achieve the thin western ideal of beauty to overcome doubts as to their own identity and feelings of estrangement from the mainstream Israeli teen society, believing that being thin will help them to identify and fit into their new culture (44). In this respect, Greenberg, Cwikel and Mirsky (35) recently found that 7.9% of young Russian female immigrants living in Israel for three years or less had pathological levels of disturbed eating attitudes and behaviors as assessed with the EAT-26 compared to both native Israeli females (19.6%) and Russian female immigrants living in Israel for a longer period of time (18.8%). The authors relate these findings to the inclination of veteran immigrants to adopt Western cultural norms in a way that may bring them closer to Israeli born young women. To our knowledge, the issue of disordered eating in new immigrants from Ethiopia to Israel has not been studied yet, probably because this group is highly secluded and inaccessible to research. We hypothesized that the problems associated with the immigration from the former FSU and Ethiopia to Israel would be reflected in the presence of increased rates of EDs in the new immigrants in comparison to Israeli-born individuals. Surprisingly, this has not been the case. Despite the massive immigration that Israel has experienced since the late 1980s, the number of immigrants seeking treatment for EDs has thus far been exceedingly low relative to their percentage within the Israeli population. This finding, albeit speculative because of the lack of valid epidemiological studies, is based on an examination of visits to the largest outpatient ED clinic in Israel, located at the Rambam Medical Center in Haifa. This clinic has been operating since 1991, and receives about 150 new patients each year. However, since its establishment, only four women from the former USSR and one Ethiopian woman have been treated at this clinic for an ED. Similarly, as of yet, only one case study describing the development of an ED in a new immigrant from the FSU has been published in Israel (45). One putative explanation for this unexpected finding is the inclination of minority groups to seek less clinical assistance in comparison with the general population, particularly in the case of psychiatric disturbances, including EDs (7,46,47). This tendency may apparently exist also among new immigrants to Israel (48). Another possible explanation relates to the inclination of general practitioners to under diagnose an ED in minority groups in comparison to native-born individuals, (49) (it should be nonetheless noted that this study has been undertaken in the USA, and the findings might be different in Israel). Both explanations cast doubt as to whether the low incidence of EDs among FSU immigrants to Israel is a genuine finding, although an extensive literature search located only one published study of AN in the FSU (50).
Eating disorder and Judaism Food is an important part of religious observance and spiritual ritual for many different faiths, including Judaism. The role of food in Jewish cultural practices and religious beliefs is complex and varies among individuals and communities. "Kashrut" refers to laws pertaining to food in the Jewish religion. ‘Kosher’ means that a specific food is permitted or ‘clean’, whereas anything ‘unclean’ (such as pork and shellfish) is strictly forbidden. The Jewish "food laws", originated more than 2,000 years ago, still contribute nowadays to a formal code of behaviour that reinforces the identity of a Jewish community.
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Food is an integral part of Jewish feast days such as New Year's Day and Passover. The food eaten in Passover, a feast commemorating the birth of the Jewish nation, helps to tell the story of the Exodus, when the Israelites left Egypt; for example, bitter herbs recall the suffering of the Israelites under the Egyptian rule. Fasting in the Bible is classified into four basic categories: As an act of mourning the dead, as an act of penitence, as an auxiliary to prayer, and as a preparation for encountering the divine (51). Ritualised fasting is also an important part of later Judaism. Yom Kippur - the Day of Atonement - for example, one of the most important days for every Jew, is a Jewish fast that lasts from dusk till dusk. Another fasting day occurs in the 9th day of the month of Av (Jewish month, typically falls around July/August), to remember and mourn forever the day Jerusalem was conquered and ruined. Furthermore, prominent Jewish religious figures in Eastern Europe in the 18th and 19th century tended to fast to abolish any physical pleasure as an act of atonement for the sins of the entire community (52). Several groups can currently be identified in terms of their level of religiosity (53): •
•
•
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•
Ultra-Orthodox Jews who believe in totally observing the old Jewish traditions and laws. Ultra-orthodox Jews tend to live in segregated neighborhoods. The two genders are kept separate during the schooling process, free selection of dates is discouraged, and sexual relations are restricted until marriage. Women are expected to marry at an early age, thereafter keeping a traditional female role. Mass media, especially television, are strictly forbidden. Orthodox Jews, who keep most Jewish traditions and laws traditions, yet are open to modern life. Orthodox Jews are somewhat less observant of the traditions of sexual segregation and of traditional gender roles. Most of them serve in the army, are exposed at least to some extent to the general Israeli mass media, and are less inclined to live in segregated neighbourhoods. “Traditional” Jews, who observe some of the Jewish traditions and laws, yet most of their daily life is conducted in a secular manner. Secular Jews, who do not observe Jewish laws and only sporadically keep Jewish traditions, except those enforced by civil law such as marriage or divorce laws.
Judaism and disordered eating in the United States The data concerning the association between Judaism and EDs in the USA are conflicting. Sykes et al (54) has found a higher prevalence of both AN and BN in American patients of Jewish background than in the general population. Baruchin (55) found that the reported rate of EDs among American Jews (13%) is higher than their overall representation in the general population (2%). The author, nevertheless, acknowledges that the interpretation of this data is limited, as it relates only to one specific treatment facility in New York. Furthermore, New York Jews have been found to seek treatment for a mental disorder in general (56), and for EDs in particular (57), to a greater extent than the non-Jewish population residing in the same area. Several hypotheses have been proposed to explain the relationship between Judaism and EDs in the USA. Steiner-Adair (58) suggested that in Jewish American families, ED-related
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preoccupations may be used to avoid mental pain, or to deal with issues related to interpersonal conflicts, including those associated with being a second or third generation of a holocaust survivor. She further regards the development of EDs in Jewish American women as an attempt to deal with feelings of inferiority associated with anti-Semitism, and as a means to change ones body to fit with the goal of achievement and assimilation, while moving away from the stereotype of the ‘Jewish mama’ to an allegedly less visible “Jewish” prototype. Greenberg (57) emphasized the importance of food in Judaism. In keeping with this hypothesis, a study (59) conducted in the Ultra Orthodox and Syrian Jewish communities in Brooklyn, found that 1 out of 19 of girls in these communities is diagnosed as an ED – a rate fifty percent higher than that reported in the general American population. This author suggests that young Jewish girls may turn to disordered eating as a means to deal with distress exactly because food is so central in the Jewish tradition. Food can assist Jewish religious women in their attempts to assert control over their lives in the face of age-specific conflictual developmental pressures: to excel scholastically, to help their parents care for their large families and, above all, to marry early and have a family of their own – often before they feel ready for it. In an environment where even cigarette smoking is strictly opposed for young women, EDs may become a way to act out their distress within the culturally sanctioned medium of food (59). By contrast, Gluck and Geliebter (60), who compared 78 orthodox Jewish American women with 48 secular Jewish women, found that that although both groups had similar mean BMI, secular women scored significantly higher than orthodox women on body shape disturbances and laxative use, showed a trend towards more vomiting and diuretic use, although they had no excessive binge-eating. The secular women were, in addition, twice as likely to have a fear of becoming fat and were four times more likely to associate selfacceptance with shape and weight-related ideals. Recently Weinberger et al (61) assessed the religious orientation and spiritual beliefs of 301 adolescent and young adult Jewish women from New York, to elucidate whether these variables have the potential to influence body dissatisfaction and disordered eating. Results Participants with an intrinsic religious orientation (i.e., relying on religious beliefs to guide important aspects of their lives) had consistently lower scores (indicating less pathology) on measures of body dissatisfaction and eating disturbance as compared to those with an extrinsic (i.e., engaging in religious activities because of the social rewards or motivators associated with these activities). High levels of spiritual well-being were moderately associated with lower levels of body dissatisfaction but showed no association with disordered eating. Overall, these findings suggest that having an intrinsic religious orientation may confer protection from eating and body image disturbance. Goldberg (62) also found that among undergraduate Jewish American female college students, an inverse relationship may exist between the degree of religiosity and the extent of body dissatisfaction and eating-related pathology. These findings may reflect the influence of another aspect of the Jewish Code of Behaviour (the "Halacha"), namely that the merit of the Jewish women is within herself, i.e., with her moral values, rather than with her physical appearance. Thus, as religious Jewish woman are expected to take on traditional gender roles of wife and mother, they are less likely to be exposed to pressures associated with physical attractiveness and with tasks requiring success and achievement outside home (63).
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Whereas the latter two studies were conducted in communal settings, Dancyger et al (64), who compared eight Ultra Orthodox Jewish women to 82 non-religious and non-Jewish women, all treated in an ED day treatment program in New York, did not find any difference in ED symptomatology presentation and course of illness between these populations. Combining all findings, we cautiously postulate that in American Jewish women, religion may protect to some extent against the development of ED-related preoccupations and behaviours in non-clinical populations. However, when a full-blown ED is already apparent, the degree of religiosity no longer has such a protective impact.
Judaism and disordered eating in in Israel To the best of our knowledge, only one study (65) has examined attitudes towards eating and disordered eating in religious Jewish adolescent girls in Israel. These girls were studying in an Ulpana - a religious educational institution for girls. A significant difference in the extent of disordered eating was found between girls with high and low levels of religiosity, namely, the more religious the girl, the less was her eating disturbed. Additionally, older girls were found to show greater religiosity, more positive self-esteem, and lower rates of unhealthy eating, compared with younger girls. These findings are related by the authors to the inclination of more religious girls to be less influenced by the mainstream Westernised Israeli mass media, to place less emphasis on physical attractiveness, and to be less geared towards success and achievement outside home. Alternatively, rigidly controlled lifestyles and strict observance of religious traditions might reduce the need to control eating and weight as a means to handle the developmental pressures of adolescence.
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Kibbutzim The term ”Kibbutz” refers to a life style in a relatively small, rural, basically communal, settlement that is conceptually based on extensive cooperation and a maximally egalitarian society, offering equal opportunities to all its members, regardless of age, gender, or any socio-economic parameter. Nowadays there are approximately 200 Kibbutzim in Israel. Several psychosocial factors make the Kibbutz a unique framework, different from the mainstream Israeli way of life. At the start, equal opportunities make women’s roles, development, and positions more non-traditional, compared with the rest of the Israeli society. In addition, in many Kibbutzim, children are raised together with their age group by special personnel and not at home with their parents. Thirdly, career development and occupational choice, as well as specific jobs offered by the Kibbutz system, are different from those of the Israeli society at large, in that they are mediated and influenced by the needs of the Kibbutz system and by available resources and opportunities, rather than by the wishes and needs of the individual. Lastly, Kibbutz members in general do not have a personal income, with the Kibbutz receiving all revenues and covers all personal as well as public needs. Although these principles are still commonly held, many Kibbutzim are currently undergoing a social change in line with more accepted Israeli social norms. Primarily, many
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Kibbutzim now have the children sleeping with their parents. Nevertheless, most of the Kibbutzim still maintain their specific basic ideology and lifestyle (53,66). EDs were considered extremely rare in the Kibbutzim until the mid 1960’s. However, assessment of the change in the annual incidence of AN among female Kibbutz members from the mid 1960’s to the late 1980’s, yielded an overall increase of 800%, an increase considered significantly greater compared to the general Israeli society (67). The trend towards high rate of disturbed eating attitudes and behaviours in the Kibbutz in the 1980’s and early 1990’s was also described in non-clinical populations. Apter et al. (39), who assessed Israeli schoolgirls of different residential settings in the late 1980th, found that more than 25% of Kibbutz girls had pathological EAT-26 scores, a significantly higher rate than that found in the other groups of Israeli schoolgirls. Kaffman and Sadeh (67) relate the increase in full-blown AN to changes in the structure of the Kibbutz, particularly in terms of an increase in food availability and consumption, and to changes in women’s perception of their gender role. Apter et al (39) attribute their finding to the unique situation of Kibbutz female adolescents in the 1980th, who are caught in a severe role conflict between the traditional nurturing female and the independent, sexually liberated “new Kibbutz woman.” Thus, Kibbutz women are expected to simultaneously succeed at their work and career, as homemakers, and as liberated women free to choose their sexual partners. From a different perspective, Kibbutz members have always tended towards greater use of medical services in general and mental health services in particular compared with the general Israeli population (39,67). A recent study has shown this trend to be present also in the case of EDs, namely the proportion of patients from the Kibbutzim seeking ambulatory treatment in the largest ED clinic in the north of Israel (16%) has been found to be considerably greater than their overall rate in the general Israeli population (1.8%), although Kibbutz members are not over-represented in inpatient ED treatment facilities The timely use of outpatient facilities may have the important benefit of reducing the need for later inpatient interventions (8). Several recent studies assessing Kibbutz schoolgirls in the late 1990’s and early 2000‘s envisioned a change in this trend. In a preliminary study conducted by Latzer and Shatz in 1997 (68,69), 19% of Kibbutz adolescent girls had a pathological EAT-26 score (i.e., EAT>20), a rate similar to that found in an urban Israeli population (Stein et al., 2003). Interestingly, just a few years later, the attitudes towards eating among female Kibbutz adolescents as assessed by the EAT-26 and the EDI-2 were already significantly less disturbed than those of adolescents in urban or rural residential settings (33,34). The authors attribute this change to a combination of three factors: First, in the last decade, the Kibbutz has undergone major socio-economic changes involved in the relocation of children to live with their parents, and in moving from an equal communal life style to privatisation. In line with these changes, the life style of Kibbutz women has become more similar to that of Israeli women in general. This decrease in the rate of maladaptive eating-related preoccupations and behaviours can also be the result of a recent implementation of an ED prevention program in the Kibbutzim (68), as a response to the increase in the rate of EDs during the 1970th and 1980th. Thirdly, the high availability and high standards of medical services in the Kibbutzim (70,71), combined with high awareness of health care and positive attitudes towards seeking
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professional help may have also potentially contributed to the decrease in the prevalence of EDs in the Kibbutzim (34,39,67).
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Israeli Arab population Approximately 20% (1.2 million) of the Israeli population consists of Israeli-Arabs, including Muslims (82%), Christians (9%), and Chircassian, Bedouins, and Druze (9%) (72). Israeli Muslim Arabs, most of them belonging to the Sunni rite, are very conscious of their culture and religion and mostly do not socialize with the Jewish population. By contrast, the Christian Arab society in Israel is closer to the Jewish majority, although sharp distinctions do remain between the two cultures. The Druze, who pay homage to Jethro (Moses father in law), live in separate villages, mostly in the Galilee. They take an active part in the national political life, including an obligatory service in the Israeli army. Most of the Druze are agriculturists who preserve their traditional way of life. The Bedouins, once highly secluded in their nomad tradition, are nowadays more assimilated in the overall Israeli way of life, having the option to serve in the Israeli army. The Chircassians are a specific Muslim group that more than any Arab minority, tend to live a secluded life in rural settings. Israeli-Arabs not only face political and economic problems related to them being a minority in a Jewish state, but experience great cultural conflicts. Whereas the Jewish Israeli population, on the whole, lives according to social codes and norms of modern Western society, the Arab minority, regardless of belonging to any specific sub-group, maintain more traditional norms and social customs, particularly with respect to gender roles, marriage and divorce, family relationships, and childrearing (48,49, 73). Nevertheless many of them are connected to cable TV and radio, and may be potentially influenced to some extent by the Israeli western way of life (74). Not surprisingly, incidence rates of EDs in Middle Eastern Muslim countries (Saudi Arabia, Pakistan, Egypt, Sudan, Iraq and Iran), as well as in Arab minorities in Western countries (e.g., the UK) are generally significantly lower compared to modernized Western countries (43,75-78). In Israel, although there are yet no valid epidemiological studies, there is some evidence to suggest that the Arab population has a lower representation among referrals to ED clinics in Israel. For example, the largest ED ambulatory service in the northern part of Israel has received more than 1,700 new referrals in the past 14 years, of whom only two AN and eight BN patients were Israeli-Arabs (8). This low incidence may reflect different attitudes toward beauty in the Arab culture, where plumpness is considered attractive and a symbol of feminine nurturance (79,80). Alternatively, it may be associated with the inclination of Israeli Arabs to refrain from seeking psychiatric assistance, related to the stigma attached to seeking help from sources outside the family support network, especially sources belonging to the Israeli state, and to having lower knowledge about EDs and ED treatment facilities (8,73). This tendency towards lower treatment seeking has been found also in ethnic minorities diagnosed with EDs in other countries (7,46,47). A few studies have attempted to assess whether different Israeli-Arab populations would show different rates of maladaptive eating-related preoccupations and behaviors. Apter et al
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(39) have administered the EAT-26 to schoolgirls belonging to five different Israeli-Arab subgroups: Muslims, Christians, Druze, Bedouins, and Circassians. The authors have found that Circassian female adolescents have the lowest percentage (8.0%) of pathological EAT-26 scores (EAT-26 >20) and the Bedouins adolescents the highest (19.4%). Muslims (18.6%), Christians (15.4%) and Druze (14.3%) fared in-between. The authors conclude that the degree of eating-related pathology depends upon the degree of exposure to Western body ideals and upon the presence of conflicts between modern and traditional perspectives in relation to the female gender role (39). Thus, Circassian adolescents live in small, relatively self-contained, endogenous communities (74) as compared to the other Arab groups. With mass media having relatively little impact on the norms and values of their life, Circassians tend to maintain the traditional female nurturing role, rendering them to be less concerned with thinness and dieting (39). By contrast, the Bedouins in Israel have undergone in recent years a rapid social change (81). In one generation, most have moved from an isolated, rural, nomadic lifestyle to a sedentary, urban existence in new towns built hastily in the south of Israel. Bedouin women, formerly isolated, protected and often veiled, have entered the mainstream Israeli society, studying in universities and working in both white- and blue-collar occupations. This exposure is likely associated with an increasing personal and socio-cultural conflict, as virginity and sexual fidelity still remain supreme values in the Bedouin society. Latzer, Tzischinsky and Azaiza (82) recently examined the prevalence of disordered eating attitudes and behaviours among different subgroups of Israel-Arab schoolgirls. Their sample included 922 (81.5%) Muslim, 125 (11.1%) Christian, and 84 (7.4%) Druze female students (7th to 12th grades) from urban and rural residential settings from all parts of Israel. The percentage of each subgroup was decided using a clusters sampling method. Compared with Druze and Muslim subgroups that had similar scores, the Christian subgroup had lower scores on all "personality" EDI-2 sub-scales, but not on the "core ED" Drive for Thinness, Bulimia, Body Dissatisfaction, and Asceticism subscales. These findings suggest that the between-group differences in EDI-2 might actually reflect the existence within the Muslim and Druze subgroups of conflicts that are not specific to disordered eating that raise overall distress. For example, Muslims girls in Israel, who are by far less involved in the mainstream Israeli culture, less educated, and of lower socioeconomic status tend to report lower selfesteem (82,83) compared with Christian Israel-Arabs, thus rendering them more vulnerable to age-specific developmental conflicts, such as the EDI-2 dimensions of maturity fears, interpersonal distrust, or social insecurity.
Discussion Israel provides an exceptional opportunity to study the role of ethnic and socio-cultural parameters in the development and maintenance of various psychological disturbances, including disordered eating syndromes, because of its unique socio-cultural background. As there are no valid Israeli studies with respect to the epidemiology of AN and BN, we have focused primarily on findings concerning disordered eating, a less defined entity. One important finding highlighted in our review is the high rate of disturbed eating in Israeli male
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and female adolescents in comparison to many other Western industrialized countries. This finding raises critical questions about the emotional well being of Israeli adolescents. Several processes might be of relevance for this increased risk. Exposure to the constant risk of terrorist threat as has been the case in Israel during most of the years of its existence, may increase risk-taking behaviours in adolescents, including those related to eating (84). The high rates of disturbed eating not only in Israeli female adolescents but also in males compared with other Western countries (29,30), lend further support for regarding disturbed eating as representing, at least in part, a reaction to stress that is not necessarily limited to one gender. Additionally, Israeli teens nowadays, who often do not identify with traditional religious, national and socio-cultural values (30), might be highly influenced by and adopt Westerns norms, including those related to the thin body ideal (31). Thirdly, more perhaps than many other nations, Israel is a society in transition (30,85) , having envisioned major socio-cultural changes within a relatively brief period of time (e.g., continuous changes in the structure of the Israeli population owing to the massive waves of immigration, or the continued switches between war and peace conditions encountered by the Israeli society). Psychological and psycho-physiological disturbances may increase within a relatively brief period in cultures in transition (86), serving as one means to cope with high levels of distress characteristic of such cultures. In this respect, although the recent increase in the incidence of EDs in Hong Kong in comparison to other parts of China (4) has been associated by the authors with a greater influence of Western ideals, another compelling explanation may relate to the greater socio-cultural changes that have occurred in Hong Kong, relative to other parts of China, since the second World War. Kibbutz communities might serve as a microcosmic socio-cultural laboratory more than any other social group in Israel because of the dramatic changes occurring in these relatively homogenous communities within a relatively brief period of time. Initially, when the Kibbutz was the explicit product of a unique, clearly articulated ideology, with the members highly involved and devoted to the Kibbutz ideology, there was an impressively low rate of reported EDs. Later, a dramatic increase in the rate of both full blown EDs and disturbed eating syndromes was observed, simultaneously with the Kibbutz becoming more open to the norms and values of the Israeli society at large, generating a conflict between the traditional Kibbutz norms and mainstream Israeli ideals. Still, more recently, the rate of disordered eating among Kibbutz adolescent girls dropped again to ranges similar to those of the general Israeli population, paralleling the socio-cultural process of assimilation of the Kibbutz into the general Israeli way of life. Although the recently reported high rate of referral of Kibbutz women to ambulatory treatment because of an ED relative to their prevalence in the general population (16% vs 1.8%), might contradict this trend, it seems to represent a greater orientation of Kibbutz members towards heath-seeking in comparison to mainstream Israeli society, rather than an increase in disturbed eating. The lower rates of disordered eating in the traditional Arab-Israeli society in comparison to the Westernised mainstream Israeli society (8,82) are in line with Keel and Klump's (4) hypothesis that the rate of disturbed eating within a specific culture is proportionate to the degree of exposure to Western values. The greater rate of eating-related pathology in Arab/Bedouins in comparison to Arab/Chircassians lends further support to the risk associated with greater exposure to Westernized ideals, as well as to the greater likelihood of individuals living in a culture at transition, as the Arab/Bedouins are, to develop psychological and psycho-physiological
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disturbances. Ruggiero and Sassaroli (87) in an extensive study of disordered eating in Mediterranean countries have similarly found that the highest incidence of disordered eating is found in those societies in which the conflict between modern Western ideals and traditional norms is the highest, as is the case in Israeli Arab/Bedouins. Altogether, our review emphasizes that the specific Israeli socio-cultural structure provides an opportunity to study the disposition to disordered eating not so much from the dichotomy of culture vs. genetics and non-shared environment (88), but rather in relation to the contribution of social instability. Namely, it is the rapid societal change, the occurrence of social instability, rather than the characteristics of the specific society that might increase the risk to develop disordered eating, and perhaps also clinical forms of EDs. These processes cut through the entire Israeli society. New immigrants who go through a major change as a result of their immigration have to integrate into the Israeli society that by itself is undergoing rapid changes, a process likely exacerbating the difficulties they endure. Similarly, Kibbutz members have experienced multiple socio-cultural changes of seemingly opposite directions within a relatively brief period of time, and Israeli Arab/Bedouins are continuously torn between their loyalty to traditional norms and their wish to be integrated in a rapidly changing mainstream Westernised Israeli society that is not always keen to accept them. Our study and previous research (41) support the notion that living in a culture in transition may increase the risk for disordered eating. A similar process has been observed by DiNicola (89), namely that what is detrimental is not so much the maladaptive influence of a specific culture to predispose to an ED (i.e., ED as a culture-dependent syndrome”) (3). Rather, it is the changes occurring within a Westernised culture that idealizes thin physique that increase the risk to develop disordered eating. According to his process, referred to by DiNicola as a “culture reactive syndrome”, rapid changes occurring within a culture may interfere with the cultural conditions for the development of a stable identity, likely increasing the risk for psychopathology. This author further argues that data on factors predisposing to an ED are mostly the result of quantitative epidemiological research. This methodology, while enabling an identification of the factors associated with the development of a clinical disorder, lacks the ability to generate theoretical formulations as to how these factors, in our case socio-cultural processes, operate to predispose to the disorder. Qualitative, in addition to quantitative data, are required to assess the putative role of socio-cultural influences in the predisposition to EDs (89). The main limitation in any analysis of EDs in Israel is the lack of epidemiological studies on these disorders, precluding any definite conclusions as to the role of socio-cultural factors specific to the Israeli society in the predisposition to an ED. This is unfortunate, as research has shown that Israeli youngsters are at continued high risk for disordered eating, and as hypotheses do exist to account for this trend, e.g., Israel being a culture in transition, a culture exposed to a constant risk to its existence, or a culture that is constantly developing. We are left with the relatively poorly defined construct of disordered eating. Furthermore, in most of the reviewed studies, disordered eating is defined with self-report questionnaires rather than with structured clinical interviews, usually considered the more valid procedure in the study of EDs (90). Nevertheless, current research usually regards disturbed eating as clinically relevant (21,90), because individuals with disturbed eating may share many characteristics common with patients with full-blown EDs (14, 21), and because between 1545% of these individuals may progress to full-blown syndromes within several years (90). The lack of valid epidemiological data does also not allow us to conclude whether the
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changes noted in the prevalence of disordered eating in the Kibbutzim in the latter half of the 20th century, and the low rates of disordered eating in the Arab society, particularly in several of its subgroups, reflect a genuine finding, or are the result of inconsistencies in the reporting of these behaviors, in sampling methods, and/or in treatment seeking behaviors.
Conclusions The picture that emerges from the current data on weight loss and eating behaviors of Israeli youth is highly disturbing, primarily as between 1994 to 2002 these problems have continued to deteriorate (32) in the context of an already grave condition (29,30). Whereas our review does not generate solutions to this serious situation, it contributes to such an endeavor, by emphasizing the risk associated with living in a culture that is both in transition and in constant socio-political stress for the development of at-risk behaviors, in our case disordered eating, This calls for the urgent elaboration of adequate interventions that would assist young Israelis to better deal with the maladaptive conditions they are faced with.
Acknowledgments We would like to thank Galia Golan-Sprinzak and Sarah Roer for their valuable assistance.
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[82] Latzer Y, Tzischinsky O, Azaiza F. Disordered eating related behaviors among Arab schoolgirls in Israel: An epidemiological study. Int J Eat Disord 2007;40:263-70. [83] Latzer Y, Azaiza F, Tzischinsky O. Eating attitudes and dieting behavior among religious subgroups of Israeli-Arab adolescent females. J Religion Health 2009;48:189-99. [84] Pat-Hornczyk R, Peled O, Miron T, Brom D, Villa Y, Chemtob CM. Risk-taking behaviors among Israeli adolescents exposed to recurrent terrorism: provoking danger under continuous threat? Am J Psychiat 2007;164:66-72. [85] Witztum E, Stein D, Latzer Y. Anorexia nervosa as a culture-bound phenomenon in the era of globalization. In: Wiesel-Lev R, Zwikel J, Barak N, eds. Mental health of Israeli women. Jerusalem: Brookdale Inst, 2005:205-28. [Hebrew]. [86] Ogden CL, Troiano RP, Briefel RR, Johnson CL. Prevalence and trends in overweight among US children and adolescents, 1999-2000. JAMA 2002;288:1728-32. [87] Ruggerio GM, Sassaroli S. Cultural and cognitive-emotional determinants of eating disorders: bridges and walls. In: Ruggerio MG, ed. Eating disorders in the Mediterranean area: An exploration in transcultural psychology. Hauppauge, NY: Nova Sci, 2003:3-17. [88] Kaye W, Strober M, Jimerson D. The neurobiology of eating disorders. In: Charney DS, Nestler EJ, eds. The neurobiology of mental illness. New York: Oxford Press, 2004;111228. [89] DiNicola VF. Anorexia multiforme: self-starvation in historical and cultural context. Transcultural Psychiatr Rev 1990;27:245-86. [90] Shisslak CM, Crayo M, Estes LS. The spectrum of eating disturbances. Int J Eat Disord 1995;18:209-19.
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In: Understanding Eating Disorders Editors: Yael Latzer, Joav Merrick, Daniel Stein
ISBN 978-1-61728-298-0 © 2011 Nova Science Publishers, Inc.
Chapter 7
A Historical, Cultural and Empirical look at Eating Disorders and Religiosity among Jewish Women
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Sarah L. Weinberger-Litman9, PhD1, Yael Latzer, DSc2 and Daniel Stein, MD3 A large body of evidence explores the positive and negative influence of religion and spirituality on a variety of psychopathology. Despite the historical link between religion and food restriction, the association between religiosity and eating disorder psychopathology has been largely ignored. However, the limited empirical and phenomenological literature examining the relationship between religion and eating disorders, suggests that religious variables seem to be of importance in the development, maintenance and response to treatment of contemporary women with disordered eating symptomatology. This issue may be of specific relevance for Jewish women whose relationship with food is historically influenced by both religious and cultural considerations. Food plays a pivotal role in Jewish culture and is used as a means of celebration, mourning and repentance; to nurture relationships and family traditions, and to achieve spiritual growth. Within traditional Judaism eating is highly structured adding to its centrality in one’s life. Anecdotal evidence suggests an inflated prevalence rate of disordered eating among Jewish, and specifically Orthodox Jewish women. However, empirical evidence does not necessarily corroborate these observations. This research is discussed and interpreted in light of cultural values and expectations placed upon young Jewish women.
9 Correspondence: Sarah L Weinberger-Litman, PhD, Marymount Manhattan College, Department of Psychology, 221 East 71st Street, New York, NY 10021 United States. E-mail: [email protected]. 1 Spears Research Institute, Healthcare Chaplaincy, New York, United States of America, 2 Eating disorders Clinic, Psychiatry Division, Rambam, Health Care Campus, Haifa and Faculty of Social Welfare and Health Sciences, Haifa University, Haifa, Israel, 3 Pediatric Psychosomatic Department, Edmund and Lily Safra Children’s Hospital, Chaim Sheba Medical Center, Tel Hashomer and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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Introduction
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And Eve took of the fruit thereof and did eat, and she gave also unto her husband…And the eyes of them both were open and they knew that they were naked…(1).
According to the Bible, it is in this brief but pivotal passage that sin is first introduced into an otherwise perfect world. It is this act of eating that causes Adam and Eve to first realize that they are naked. They are immediately filled with shame, and in the following verse actually attempt to hide from God. Essentially, this is mankind’s first revelation about sexuality. Thus it is from the beginning of time that the connection between food and sexuality is established, and both are seen as something sinful or emerging from sin. The sin is committed through an act of eating by Eve, a woman, who presumably cannot control her impulsive nature. Furthermore, God punishes eve by bestowing upon her the curses of menstruation (2) and painful childbirth (3). Therefore the essence of one’s womanhood, her reproductive capabilities, is a curse, and can be viewed as shameful and deserving of atonement or repentance. Some have looked at Eve’s transgression and its association with sexuality and femininity as one possible explanation for why throughout time, women have felt the need to express themselves through their bodies and why the denial of food has historically been a popular choice among women as a means of religious devotion (4). A historical look at women’s relationship with food and their bodies illustrates the ways in which denial of food was used to attain spiritual salvation. For example, as described in an earlier chapter in this book (5), deliberate self starvation among young Christian women in the earlier and later medieval periods, was done as a means to release these women from unbearable anxieties related to femininity and sexuality. In early and late medieval times, fasting among young Christian women of the elite was quite common, with many also engaging in other forms of self-mortification. This deliberate self-starvation was done, at the start, to free these women from unwanted marriages imposed by their parents, but later became a means for of self purification, and for becoming closer to God, (6,7). Many of these women were admired for their sacrifices and declared saints by the church while still living. For example, Saint Veronica (C. 1st Cen. C.E. ) would fast for days and eat only Orange seeds on Fridays (6,8). Columba of Rieti (1467-1501), who eventually died of starvation, was reported to have also severely mutilated her breasts and hips, possibly as a means of alleviating herself from unbearable anxieties related to issues of femininity and (6,8). Perhaps the most well known of these fasting saints was Catherine of Siena (13471380), who reportedly was unable to eat more than handful of herbs each day and when forced to eat would purge with a twig (8). While extreme, these examples illustrate the ways in which women used their bodies as a vehicle for self-denial and transcendence of the physical, and were revered for their sacrifice and commitment (6-8). The ability to survive without any or with very little food was considered miraculous and a testament to the sanctity of these women and their actions and became known as “anorexia mirabilis,” a miraculous loss of appetite, conceived in the late middle ages as "holy anorexia:" (6,8). Furthermore, while asceticism was certainly seen among male religious figures, by the middle ages it was vastly more common among women than men (6-8).
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After the medieval period, the phenomenon of surviving on little (or no) food for religious purposes remained common but was seen mainly in adolescent girls and younger women. Especially in Western Europe, there were several documented cases of fasting girls, and many people traveled great distances to merely be in the presence of these miraculous maidens. This severe restriction of food was a reflection of the ascetic and austere lifestyle characteristic of many women as a way of espousing their religious faith and devotion (6). Their ultimate goal was to transcend physical needs thereby ensuring salvation and acceptance by God (4). While occasionally met with skepticism, a possible reason that these fasting girls were so widely accepted by the public was because they became a prototype for religious devotion; these women represented a complete denial of the flesh and separateness of body and soul (6, 8). It was not until 1689 that Richard Morton first described this phenomenon as an illness of a hysterical nature, and it was Sir William Gull that finally named this condition Anorexia Nervosa (AN) in 1874 (6). One cannot help but draw parallels between “anorexia mirabilis” of the medieval and Victorian eras and anorexia nervosa and other eating disorders (EDs) seen today. The denial of food and manipulation of their bodies has historically been the vehicle of choice for women to express not only their religious devotion but also to achieve control over situations. Historically, fasting and feeding others such as the poor were socially sanctioned forms of asceticism and thereby allowed women to take control of their bodies and their sexuality. From a religious perspective, medieval women sought to completely deny their sexuality and physical needs via the restriction of food. Even in ancient times, fasting was recognized to suppress menstruation, sexual desire and fertility as well as control a variety of other physical sensations and functions (8). It was widely believed that women’s bodies and physical needs were vessels of sin and that suffering and the denial of physicality were a way to achieve spiritual salvation (6, 8). It is crucial to note that modern day women with EDs do not just attempt to restrict food intake but rather, their asceticism may also extend to other domains of the physical, particularly areas involving sexuality and femininity (6,7,9). Ambivalent feelings about sexuality are often a central issue in EDs as is highlighted by the fact that many cases develop at the onset of puberty (10-12). Interestingly, it has been documented that the fasting of several medieval women also began at the onset of menstruation or when forced to marry (8). From a sociocultural perspective ancient and medieval women used food as a means of control because there was little else in their lives that they could control (6, 8). Traditionally the preparation of food and feeding of the family has been the role of women. In fact in some respects a woman is herself food in the case of nurturing a fetus in the womb or breastfeeding a baby (8), and so for many women denial of food was a complete denial of themselves. Many fasting saints sought power through control of their bodies in a patriarchal society where a complete denial of physical needs and a life devoted to God was the only way to avoid marriage or influence other life circumstances(13). Both fasting saints and modern day women with EDs struggle for control and autonomy in a world perceived as dominating and chaotic. Medieval women did not exhibit the fear of fatness or pursuit of thinness characteristic of modern EDs, however their pursuit of holiness as an expression of power consumed them to the same extent that modern women pursue physical perfection. Similarly women with EDs today pursue thinness in a culture in which it is sanctified and hallowed and where media images have an almost iconic quality (4).
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Ultimately holiness in medieval times and thinness in modern times both represent cultural ideals for women.
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Research, religion, mental health and ED Contemporary research suggests that religious beliefs remain a salient factor to consider in ED development (13). Similar to early and late Medieval women, EDs nowadays may be connected to religious beliefs, either directly or indirectly (4), as a means to increase a sense of self-control, and bring about a kind of salvation from the so-called femininity-related and sexuality-related "sins of the flesh" (6,7,9). While few women with eating disturbances admit to, or are consciously aware that their eating disorder is linked to religious beliefs, religious trends emerge from the scant research that has been conducted in this area. Some studies have revealed a direct relationship between AN symptoms and religious devotion, and an inverse relationship between bulimia nervosa (BN) symptoms and religious devotion (14-16). According to these authors, some women with restricting AN symptoms may feel successful in controlling their impulses and transcending their physical needs, and their asceticism is likely used as a justification for food restriction. Women with BN symptoms on the other hand, may feel that they have succumbed to temptation through their eating binges and therefore have failed in their quest for impulse control. Furthermore, Smith, Richards and Maglio (16), found that among women with clinical or subclinical BN, those with an extrinsic religious orientation (i.e. individuals that are religious primarily for social reasons) had higher levels of ED symptomatology than those with an intrinsic religious orientation (i.e. individuals that internalize their religious values). Similarly, this group (15), concluded that over the course of ED treatment, individuals increasing in spiritual well-being showed a decrease in ED symptoms and an increase in overall psychological functioning. The aforementioned studies relating the complex nature of the association between religion and EDs are consistent with the general literature related to religion, spirituality and mental health. Overall, research suggests that religion positively influences mental health by helping individuals construct meaning and set goals, and by increasing overall life satisfaction. Social support appears to account for a large part of the impact that religiosity has on favorable mental health outcomes (17). In addition to the role of social support, religious beliefs and involvement in religious activities has been shown to have positive effects on psychosocial functioning and well-being in adults as well as in children and adolescents (17). Religious teens are less likely to engage in risk-taking behaviors and have lower levels of depression and anxiety. This protective role of religion is thought to be a result of religion playing a pivotal role in the formation of identity. Alternatively, it can be related to the inclination of religious teens to select a peer group that reinforces these values (17). This association between religious values and the development of EDs, is one example of the importance of teens having solid meanings and values in general in an attempt to reduce the risk of developing an ED during the unstable period of adolescence Other studies however, have shown that psychopathology can be exacerbated by religious beliefs when they reinforce guilt or anxiety (18). A high level of rigidity associated with religious belief or observance likely has a negative impact on psychosocial functioning. This may be especially detrimental to mental health among children growing up in homes with
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religiously rigid parents who can increase feelings of guilt or foster a religiously-related punitive attitude (18). Thus, while religiosity and spirituality can be protective and helpful in predisposed individuals before the actual appearance of a psychiatric illness, religious individuals often incorporate religious elements into their symptoms or cognitions, when this illness is already present (17). In the case of EDs, this is evidenced by the finding that some women may use religion as a basis for asceticism and food restriction, or to justify ED-related obsessional symptomatology (19). The duality in the association of religiosity and mental health has led Richards, Hardman and Berrett (13) to develop a theistic view of EDs, which argues that for many women, spiritual and religious issues lie at the very core of their ED. Based on their vast experience treating women with EDs, these authors conclude that EDs may fundamentally impair ones ability for spiritual growth and connection not only with a God or a higher power, but also impedes upon one’s ability to form meaningful and loving interpersonal relationships. Furthermore, the authors observed that religious women with EDs have sometimes been found to develop negative and punitive images about God or religion. Adding to the multifaceted picture associating religion and EDs, the authors of this chapter suggest that the development of an ED may represent in some cases, an escape from conflicts related to religion, a legitimate solution to these conflicts, or a means to postpone an early unwanted marriage to which young adults may feel unprepared.
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Judaism, food and eating disorder A large body of evidence explores the positive and negative influence of religion and spirituality on a variety of psychopathology (20). Despite the limited empirical and phenomenological literature examining the relationship between religion and EDs, religious variables seem to be of importance in the development, maintenance and response to treatment of ED patients. This issue may be of specific relevance for Jewish women whose relationship with food is historically influenced by both religious and cultural considerations. This is particularly the case among Orthodox Jews, for whom many domains of life are structured by religious mandates related to food.
Denominational distinctions in Judaism The extent to which Jewish people adhere to the accepted laws and customs varies by their level of observance and by their affiliations. Orthodox Judaism strictly adheres to both biblical (Torah), and Talmudic/rabbinic Laws, or Halakha. Contemporary Orthodox Judaism largely maintains the same basic philosophy and legal framework that has existed throughout centuries of Jewish history. The term Orthodox was first used in the 19th century to differentiate traditionally observant Jews from the newly formed Reform movement which sought to modernize Judaism by eliminating varying aspects of observance. However, even within Orthodox Judaism there exist many differing philosophies regarding the extent to which Jews should integrate into mainstream society, which has engendered the distinction between Haredi and Modern Orthodox Jews. Haredi Jews, which also include Hasidic or
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Ultra-Orthodox Jews, adhere to the strictest interpretation of the Halakha and to varying degrees live, to the extent possible, separate lives from secular culture. Haredi Jews often live is small close-knit communities, and traditional gender roles are upheld. Modern Orthodox Jews maintain a Torah observant lifestyle while to varying degrees integrate elements of secular culture into their lives particularly with regard to secular education and careers. This group often feels that the intersection with modern society can have an important role in enhancing Judaism (21, 22). Conservative Judaism originally began at the intersection between Orthodox and Reform Judaism. Conservative Judaism believes in the importance of Halakha but allows for greater rabbinic interpretation and modernization of these laws. Conservative Judaism also allows for complete gender equality, this being one of its main differences from Orthodox Judaism (21, 22). Reform, and more recently Reconstructionist Judaism represent the most liberal branches of Judaism. These branches do not believe that Jewish law or Halakha is binding but recognize the cultural and historical value of these laws. Jews of these denominations lead mainly secular lives but often incorporate Jewish customs or rituals into their family and communal lives (22). It is important to note that these distinctions are mainly related to the Jewish life in North America, whereas different divisions exist in other Jewish communities around the world, specifically in Israel.
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Food and Judaism Food plays an integral role in the Jewish culture and home environment, similar to other cultures and religious traditions. The Sabbath, as well as each Jewish holiday, is often centered on special foods and large family meals. Among Jews, food is used as a medium to express love and concern. Sabbath and holiday meals often include members of one’s extended family and other guests, and are seen as a way to nurture and cultivate these relationships (23). Food prepared for specific occasions may not only have symbolic cultural or religious significance, but often represents family traditions and historical ties to countries of origin such as the different regional foods of Ashkenazi and Sephardic Jews (24). Independent of what food represents on a cultural level, Jewish tradition offers both pragmatic and philosophical explanations of the function of food. The question of the role that food plays in one’s life is a complex one which has been extensively explored by ancient and contemporary scholars alike. In traditional Judaism, eating is highly structured. The laws regarding keeping kosher, or Kashrut, govern virtually every aspect of food preparation and consumption, and differentiate permissible from non-permissible food types (25). To observant Jews, Kashrut is one of the fundamental tenets of a Jewish lifestyle. Additionally, individuals must recite special blessings before and after eating all foods, with complex laws dictating the specific blessing that are to be recited over various foods. Furthermore, Jews are required to eat three meals over the Sabbath and two meals every holiday. Each of these meals is supposed to include a wide variety of foods (25). Additionally, throughout the year there are fast days where one must abstain from all food and drink, and days where certain foods are prohibited. Pragmatically, there exists in Jewish law the widespread recognition that eating and drinking are essential elements necessary for maintaining one’s health (25). At the same time
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there is likewise a widespread belief among many religious Jews that food serves a spiritual, in addition to a corporeal role (26-28). Eating can be viewed as both a physical and spiritual act, and is seen by some as a medium through which to uplift oneself so that both food and its consumption become infused with spirituality and meaning (25). Many scholars have posited that the laws of Kashrut are meant to encourage mindfulness with regard to eating and other physical needs (26, 29). Some Jewish sources also regard individuals that are capable of controlling their desires relating to food and drink as able to show reverence towards, and become closer to God (26). This line of thinking is evident in the work of Rabbi Moshe Chayim Luzzatto a prominent 18th century Italian rabbi and philosopher, whose writings have become one of the most authoritative sources of moral behavior in traditional Judaism (28). He suggests steps by which a person can reach righteousness through careful scrutiny of one’s actions. One means of achieving piety is through abstinence from certain physical pleasures including the excessive eating of pleasurable foods. Luzzatto, however, is careful to separate this idea of abstinence from asceticism. In Judaism one is considered to have sinned if one continually abstains from essential physical needs. Furthermore, he concludes that within Judaism, although asceticism can be a way of attaining spiritual growth for some individuals, it is not expected, or encouraged of everyone (28).
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Jewish women and eating disorders Within Judaism food represents a multifaceted and complex entity related to purity, spirituality, physical sustenance, and atonement. The central, yet conflicting roles that food plays in the Jewish culture as highlighted in the previous section, may intensify negative feelings surrounding food and/or body image in vulnerable individuals, or those already struggling with these issues. This may be especially true in a culture where food is often used to express emotions and cultivate relationships, and where issues related to control of food and to abstinence are seemingly of paramount importance. Furthermore, among Orthodox teens, in addition to food consumption being highly controlled as a result of keeping kosher, many other “typically teenage” activities are also limited as a result of restrictions surrounding dating, sexuality and integrating with mainstream culture. From a different perspective, despite the recommendations of famous Jewish authorities with respect to abstinence, contemporary Judaism does not officially endorse asceticism or the denial of physical pleasures. Nevertheless, abstaining from food and sex is mandated in specific circumstances for example on certain fast days. These processes may explain why food has become, for Orthodox girls and young women, a means to gain a sense of control over their life (30), and a potent expression of rebellion or distress. The association of food with issues related to control and purity can also account for its' association among religious adolescents with ambivalent feelings about physical needs in general. This is evident, first and foremost, by the potential for amenorrhea, due to severe reduction of food intake, to delay an unwanted marriage among Ultra-Orthodox young women who feel unready for this developmental event. Despite evidence to suggest that higher levels of religiosity and spirituality are beneficial to overall mental health, anecdotal evidence suggests an inflated prevalence of EDs among Jewish women, particularly in the case Orthodox Jewish women (30-32). An unpublished
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study, cited by Baruchin (30), of Orthodox women in the New York area found that as many as 1 in 19 Jewish women may struggle with an ED. Furthermore, two books have been recently written by prominent Rabbis (33,34) about EDs among Orthodox Jewish adolescents and young women in the New York City area. These books have been written in the hope of destigmatizing EDs within a community reluctant to openly discuss psychiatric issues, and to help young women obtain treatment. Unfortunately, the publication of these books generated a concern with respect to an alleged increase in the incidence of EDs among Jewish Orthodox youngsters in New York. It should nevertheless be noted that these conclusions were based only on anecdotal case studies. Some empirically-based studies have shown religiosity to be positively associated with psychological adjustment (17), and with less appearance of disordered eating among Jewish women with a greater religious affiliation (35,36). Gluck and Geliebeter (35) compared 78 Orthodox Jewish college students with 48 secular Jewish college students in the United States. The results indicated that despite having similar body mass indices, the secular women scored significantly higher on body dissatisfaction and on laxative abuse than the Orthodox women. The secular women were twice as likely to have a fear of becoming fat and were four times more likely to be influenced by issues related to shape and weight. The authors related their findings to the possible reduced exposure of Orthodox Jewish women to the mainstream media and to less emphasis in this group on physical appearance. Latzer, Tzischinsky and Gefen (36) suggest that Israel as a society is coping with the same epidemiological trends as other Western societies, and studied the relationship between religious affinity, self esteem, and disordered eating-related psychopathology among 320 Modern Orthodox Jewish adolescents (grades 9-12). Similar to Gluck and Geliebter (35),the results indicated a negative association between level of religiosity and disordered eating. The youngest students (grade 9) were found to be the least religious and to have the highest eating-related psychopathology, whereas the oldest students (grade 11-12) were the most religious and had the least eating-related psychopathology. Recently, Latzer et al also (37) examined risk factors for EDs among Modern Orthodox high school seniors in Israel (grade 12), showing that their rates of ED symptomatology as measured with standardized ED questionnaires, were significantly lower in comparison to the general population of similar age in that area. Altogether, these studies suggest a protective factor associated with increased levels of religiosity with regard to ED development; however it is noteworthy that these studies were conducted in community rather than clinical samples, relating to disordered eating rather than to clinical EDs. Other studies do not support the connection between increased observance and ED symptoms. In a small clinical study, Dancyger et al (38), investigated women in an ED day treatment program, comparing Orthodox Jewish women, with both non-religious Jewish women and non-Jewish women. The authors found no between-group differences in ED symptomatology and treatment outcome, although Orthodox patients remained in the program significantly longer than the other groups. Similarly, a recent study by Weinberger-Litman et al (39), found no significant differences in ED symptomatology between Orthodox and non-Orthodox Jewish women in a sample of 301 undergraduates and high school students. However, significant differences in disordered eating and body dissatisfaction were found between those with in intrinsic religious orientation (i.e. those that internalize and live their religious values), versus those
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with an extrinsic religious orientation (i.e. those that engage in religious activities because of social pressures or rewards) (39). Therefore, while differences were not seen for level of observance (which is how religiosity is generally measured), they were found for different types of religiosity. This is consistent with other studies showing that an extrinsic orientation is associated with higher levels of ED symptoms (16) whereas an intrinsic religious orientation is associated with more positive mental health (17). The findings of the study by Weinberger-Litman and colleagues suggest that the discrepancies previously seen with regard to the association of religiosity with ED symptomatology may relate to methodological issues in conceptualizing religiosity. Furthermore it is likely that Latzer et al.’s (40) finding that increased religiosity is associated with lower levels of ED symptoms, can also be related to an increase in intrinsic religiosity, rather than just greater observance. In a similar vein, a recent study examining Modern Orthodox high school girls in the United States has also failed to find a relationship between level of observance and ED symptomatology but has found an association between negative religious coping and ED symptoms (41).In this study, similarly to what has been found regarding other forms of psychopathology (42), adolescents who viewed God or religion as more punitive and less forgiving, exhibited higher levels of disordered eating. The discrepancies between anecdotal and empirical evidence regarding the prevalence of EDs among Orthodox women are likely the result of several issues. Firstly, prevalence estimates cannot be accurately assessed because, to date, there have been no large scale epidemiological studies examining both clinical and non-clinical samples within the Orthodox Jewish community. Secondly, prevalence based on non-clinical undergraduate or high school samples may not accurately generalize to the rest of the population. Thirdly, a high percentage of Orthodox patients seen in private practice may reflect help-seeking characteristics of Orthodox families or a greater awareness of the dangers of EDs (32) rather than an inflated rate of EDs. Finally, evidence that religiosity may be associated with lower levels of EDs is not entirely incongruent with anecdotal evidence of a high prevalence of EDs among Orthodox Jews. Given the evidence that different aspects of religiosity may be more beneficial than others (15, 20, 39), coupled with other evidence that religiosity can have both positive and negative effects on mental health (17-19), it is plausible that within a highly religious community certain individuals may be put at an increased risk while others are buffered from the development of EDs.
Understanding eating disorders among Jewish women The above studies paint a complex picture of the association between religiosity and EDs among Jewish women, specifically in the case of Orthodox Jewish women. It is unclear whether the prevalence of EDs among Orthodox Jewish women is higher than that of the general population. Although to the best of our knowledge there are no empirical studies with respect to the rates of EDs in the Jewish Orthodox population, EDs seem to represent a definite problem within this community. Although not investigated empirically, some authors have suggested that the complex and central role that food plays in Jewish culture along with the laws of Kashrut that create a
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sense of rigidity surrounding food preparation and consumption, may, in vulnerable individuals, enhance the predisposition to develop an ED, (30,31). Additionally, other domains specific to the Jewish community may further increase this vulnerability. Weinberger-Litman (40) found that the relationship between religious orientation and ED symptomatology may be mediated to some extent by adherence to the Superwoman Ideal and thin-ideal internalization. In line with these findings, it has been previously suggested (10,43) that adherence to the Superwoman Ideal, which represents conflicting gender roles and the idea that one must “have it all” to be successful, is associated with greater levels of disordered eating. The pressures facing contemporary Orthodox Jewish women are both similar to and unique from mainstream culture and likely render the concept of the Superwoman particularly salient among this group. In many ways, among Orthodox women traditional gender roles are both changing and being rigidly enforced. Similar to the general culture, Orthodox women are facing greater pressure to excel academically. Within Modern Orthodox circles this usually entails attending a prestigious university and obtaining an advanced degree. Among Haredi Jewish women, the importance of a career may not be emphasized but women are often expected to work outside the home to support a large family and/or a husband who has devoted his life to Torah study. This academic pressure, however, is often in contrast to traditional expectations of Jewish women. Another issue potentially contributing to increased conflicts in Modern Jewish Orthodox women is the extreme pressure to marry at a young age (31,33,44). As mainstream standards of beauty have become more rigid and unattainable, the idea of what constitutes a suitable bride has become increasingly thinner and more unrealistic, even among segments of the community with fairly limited media exposure. Traditionally, dating is carried out strictly for the purpose of marriage, with family members often arranging these dates because communication between the sexes is limited (33,44). Within Modern Jewish Orthodox social circles, it has recently become almost a common practice to inquire about a girl’s dress size before arranging dates, and some have even begun to ask what size her mother wears (33,44). Originally this formal dating process was designed to protect young women from the emotional difficulties associated with casual dating and sexual relationships, and to help one find a spouse with similar core beliefs and values. In our modern times this system may still confer emotional benefits for some young women, but for others it can be detrimental when the focus is no longer on character and values but rather on dress sizes and outward appearance. Orthodox Jewish women are not only expected to conform to rigid appearance standards, but they also are expected to do so within the boundaries of Tzniut, or modesty laws. Briefly, these laws prohibit women and girls over 12 years of age from exposing any skin above the elbows or knees or below the collarbone (45), and many women also cover the lower legs with stockings. While the essence of these laws is about modesty and self-respect, they are often rigidly enforced and may be misinterpreted by adolescent and young women. For example, they may serve to induce shame about one’s body or sexuality. Furthermore, for many Orthodox girls, formal dating for marriage is the first real interaction with boys, and all physical and sexual contact is prohibited until after marriage (25). While these laws are essentially about teaching women the value of their sexuality, they can feel oppressive and shameful to young women that are ambivalent about their sexuality or with respect to the expectation to marry at a young age.
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Conclusions Consistent with the general research examining religion and mental health (17-19), studies exploring the relationship between religion and EDs have shown that religiosity can have both a beneficial and a detrimental influence (35,36,39). Among Jewish, specifically Orthodox Jewish, women, this relationship may be even more complex. Modern-day Jewish women may act according to similar or different motives in comparison to medieval fasting women, yet in both populations cultural/religious influences may have an important influence in the predisposition towards EDs. For example, the concept of the Superwoman in Judaism may be embodied by the book of Proverbs’ “woman of valor” or Eshet Hayil (46). Although it is meant as an allegory, the literal reading of the Eshet Hayil reveals a woman who puts everyone’s needs above her own, as it states: “Her husband’s heart relies on her and he shall lack no fortune…She repays his good but never his harm all the days of her life…She anticipates the ways of her household and partakes not of the bread of laziness…False is grace and vain is beauty… a God fearing women she should be praised”. In Orthodox homes, the Eshet Hayil is recited every Friday night and Jewish girls are taught that its values are ones to aspire to. Traditionally, the fulfillment of all female roles has been in harmony with the Eshet Hayil concept. By contrast, the Modern orthodox Jewish woman has to function in a sense as a "Super Eshet Hayil" having to fulfill both traditional and modern gender-role expectations, potentially engendering an ideal that is almost impossible to live up to. For some individuals the rigidity associated with an Orthodox lifestyle coupled with underlying psychological vulnerabilities may contribute to the predisposition to develop an ED, whereas for other women, elements of Jewish religious life may be a protective buffer against developing EDs. Studies have shown that the benefits of religion for adolescents come primarily from the formation of identity and meaning in one’s life (17). We suggest that every culture has its own values and expectations, which for the most part serve to assist the individual to direct his or her life and give life a meaning concurrent with the expectations and demands of the culture. However, some individuals may find it harder to adjust and comply with these expectations. In the case of young Jewish Orthodox women, conflicts regarding cultural demands and expectations may increase the risk towards disordered eating only in specifically vulnerable cases. This may relate to young girls who are highly perfectionistic in almost every aspect of life in order to overcome extremely low self-esteem (engendering an identity of the "Super Eshet Hayil"). This may also relate to other girls having to overcome their sexual urges in the face of highly rigid families, likely engendering a fragile sense of ineffectiveness and threatened loss of control by adhering to the norms of Tzniut. For some Jewish women, such as those who have an intrinsic religious orientation, Judaism may provide a framework in which to develop a complete sense of self. Engaging in religious communal life and adhering to Jewish laws and customs may provide a sense of security and an extensive social support network. Those for whom Judaism enables a coherent identity to develop may be less vulnerable to developing EDs. Additionally, some women with EDs may find certain elements of religion or spirituality helpful in their recovery. What emerges with regard to Jewish women and EDs is a complex picture, whereby it is clear that for many women religious variables should be considered with regard to the prevention, etiology and treatment of EDs.
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Acknowledgments The authors would like to thank Hillel Goldschein, Leib Litman, Moshe L. Miller and Rabbi Charles Sheer for their helpful comments on sections of this chapter.
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[20] Paloutzian RF, Park CL, eds. Handbook of the psychology of religion and spirituality. New York: Guilford, 2005. [21] Heilman SC, Cohen SM. Cosmopolitans and parochials modern orthodox Jews in America. Chicago, IL: Univ Chicago Press, 1989. [22] Wouk H. This is my God: The Jewish way of life. Boston: Little, Brown, 1988. [23] Greenberg B. How to run a traditional Jewish household. Northvale, NJ: Aronson, 1989. [24] Nathan J. A social history of Jewish food in America. In: Greenspoon LJ, Simkins RA, Shapiro G, eds. Food and Judaism. Omaha, NE: Creighton Univ Press, 2005. [25] Ganzfried S. Code of Jewish law. New York: Hebrew Publ Company, 1864. [26] Brumberg-Kraus JD. Does God care what we eat? Jewish theologies of food and reverance for life. In: Greenspoon LJ, Simkins RA, Shapiro G, eds. Food and Judaism. Omaha, NE: Creighton Univ Press, 2005. [27] Dessler EE. Strive for truth. New York: Feldheim, 1954. [28] Luzzatto MC. Path of the just. New York: Feldheim, 1738. [29] Abusch-Magder RA. Kashrut: The possibility and limits of women's domestic power. In: Greenspoon LJ, Simkins RA, Shapiro G, eds. Food and Judaism. Omaha, NE: Creighton Univ Press, 2005. [30] Baruchin A. What can Orthodox girls control? Lilith 1998;23:8. [31] Altmann E. Eating disorders in the Jewish community. In: My Jewish Learning.com; 2007. [32] Steiner-Adair C. Cultural sensitivity and eating disorders primary prevention: The adaptation of an effective primary prevention program for Jewish girls. Int J Child Adolesc Health 2008;1(4):305-12. [33] Goldwasser D. Starving to live. New York: Judaica Press, 2001. [34] Twerski AJ. The thin within you: Winning the weight game with self-esteem. New York: St Martin's Griffin, 1999. [35] Gluck ME, Geliebter A. Body image and eating behaviors in Orthodox and secular Jewish women. J Gender Spec Med 2002;5:19-24. [36] Latzer Y, Orna T, Gefen S. Level of religiosity and disordered eating psychopathology among modern-orthodox Jewish adolescent girls in Israel. Int J Adolesc Med Health 2007;19(4):511-21. [37] Latzer Y. In preparation. [38] Dancyger I, Fornari V, Fisher M, Frank S, Sison C, M.Charitou, et al. Cultural factors in orthodox Jewish adolescents treated in a day program for eating disorders. Int J Adolesc Med Health 2002;14(4):317-28. [39] Weinberger-Litman SL, Rabin LA, Fogel J, Mensinger JL. The influence of religious orientation and spiritual well-being on body dissatisfaction and disordered eating in a sample of Jewish women. Int J Child Adolesc Health 2008;1(4):373-87. [40] Weinberger-Litman SL. The influence of religious orientation, spiritual well-being, educational setting, and social comparison on body image and eating disturbance in Jewish women. New York: City Univ New York, 2007. [41] Latzer Y, Weinberger-Litman SL, Isaacs J, Gerson B, Silver J, Pelcovitz D. Negative religious coping predicts eating disorder symptomatology among Jewish adolescent girls. In preparation. [42] Pargament KI. The psychology of religion and coping. New York: Guilford, 1997. [43] Mensinger JL, Bonifazi DZ, LaRosa J. Perceived gender role prescriptions in schools, the superwoman ideal and disordered eating among adolescent girls. Sex Roles 2007:557-68.
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[44] Weinberger-Litman SL, Rabin LA, Fogel J, Mensinger JL. Educational setting and risk factors for eating disorders among young Jewish women: A comparison between singlegender and coed schools. Couns Spirituality 2008;27:131-56. [45] Falk PE. Modesty: An adornment for life. New York: Feldheim, 1998. [46] The Bible. Proverbs 31: 10-31 In. New York: Judaica Press.
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Section Three: Etiology
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In: Understanding Eating Disorders Editors: Yael Latzer, Joav Merrick, Daniel Stein
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Chapter 8
Eating Disorders in the Mediterranean World Giovanni M. Ruggiero10, MD and Sandra Sassaroli, MD
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Psicoterapia Cognitiva e Ricerca, Post-graduate Cognitive Psychotherapy School, Milano and Studi Cognitivi, Post-graduate Cognitive Psychotherapy School , Milano, San Benedetto del Tronto, Italy Recent studies carried out in Mediterranean countries indicated that dieting attitudes and eating disorders are increasingly spreading throughout this area. The aim of this chapter is to discuss the phenomenon from a cognitive and transcultural point of view. At the present time the Mediterranean world is one which tends to import western cultural standards, modern social habits and independent ways of thinking, yet attempts to retain jealously its traditional values. This transitional condition gives us the possibility to explore the interaction between psychological and socio-cultural risk factors for eating disorders, such as parental criticism, perfectionism, self-esteem and body dissatisfaction. In Mediterranean countries parental criticism toward their adolescent children (which are subjects at risk for eating disorders) presents itself as a cultural conflict. Parents’ sometimes stringent traditionalism and adolescents’ sensitivity to western values of autonomy and bodily thinness are currently clashing with each other. Parental criticism might facilitate or reinforce a child's eating disorder more often than not, leading the subjects to perfectionism and low self-esteem, both of these having been identified as important determinants of such disorders. Studies carried out in various Mediterranean countries (i.e., Spain and Turkey) reached the conclusion that the modern ideal of a perfectly thin body has entered in their culture. In addition, studies conducted in other Mediterranean areas (i.e. the south of Italy) ascertained that there teens would be less sensitive to thin body ideals promoted by the media, yet presenting other psychological determinants of eating disorders such as low self-esteem and high perfectionism.
10 Correspondence: Giovanni M Ruggiero, “Studi Cognitivi”, Foro Buonaparte 57, 20121, Milano, Italy. E-mail: [email protected].
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Introduction Cultural values and beliefs have been identified as significant factors in the development of eating disorders. Historical and cross-cultural experiences suggest that cultural change itself may be associated with increased vulnerability to eating disorders, especially when values about physical aesthetics are involved. Such change may occur across time within a given society, or on an individual level, as when an immigrant moves into a new culture (1). Prince (2) described anorexia nervosa as a possible “culture-bound syndrome,” with roots in Western cultural values of autonomy, emancipation and masculinized and thin ideal of feminine beauty. In the United States, eating disorders seem to have become more common among younger females during the latter half of the twentieth century, during a period when icons of American beauty (Miss America contestants and Playboy centerfolds) have become thinner and women’s magazines have published significantly more articles on methods for weight loss (3-5). DiNicola (6) has proposed that anorexia nervosa is less a culture-specific syndrome than a culture-change syndrome of communities that are modernizing. According to this hypothesis, migrants and individuals in cultures that are changing are especially vulnerable to developing eating disorders. Pumariega (7,8) has also proposed that acculturation to Western ideals of attractiveness and body size is an increasing phenomenon that has a particularly powerful impact on developing adolescents, who are in the midst of establishing their psychological and cultural identity. Traditional cultures may have protective factors against the development of eating disorders. The question is: is this model applicable to the Mediterranean area? Recent studies carried out in Mediterranean countries indicate that dieting attitudes and eating disorders are increasingly spreading throughout this area. The aim of this article on eating disorders is to discuss the phenomenon from a cognitive and transcultural point of view. At the present time the Mediterranean world is one which tends to import western cultural standards, modern social habits and independent ways of thinking, yet attempts to retain jealously its traditional values (9-12). This transitional condition gives us the possibility to explore the interaction between psychological and socio-cultural risk factors for eating disorders, such as parental criticism, perfectionism, self-esteem and body dissatisfaction. In Mediterranean countries parental criticism toward their adolescent children (which are subjects at risk for eating disorders) presents itself as a cultural conflict. Parents’ sometimes stringent traditionalism and adolescents’ sensitivity to western values of autonomy and bodily thinness are currently clashing with each other. Parental criticism might facilitate or reinforce a child's eating disorder more often than not, leading the subjects to perfectionism and low self-esteem, both of these having been identified as important determinants of such disorders. Studies carried out in various Mediterranean countries (i.e., Spain and Turkey) reached the conclusion that the modern ideal of a perfectly thin body has entered in their culture. In addition, studies conducted in other Mediterranean areas (i.e. the south of Italy) ascertained that there teens would be less sensitive to thin body ideals promoted by the media, yet presenting other psychological determinants of eating disorders such as low self-esteem and high perfectionism. The number of studies relating to eating disorders in the Mediterranean area is not voluminous. Research was conducted in Spain, Italy, Greece, Turkey, Israel and Egypt.
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Within the body of this research, we can distinguish epidemiological and socio-cultural studies. The epidemiological works suggest that the prevalence of eating disorders in the Mediterranean countries is either as high as in the north of Europe, or increasing. The sociocultural studies (i.e. those which attempt to investigate the connection between socio-cultural influences and the rising levels of eating disorders) are not homogeneous in terms of aims, design, or methodology. Thus, comparative analysis of the findings is difficult.
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Spain According to Bosch (13), the current prevalence of eating disorders in Spain is of much concern and disturbing. Recent estimates indicate that 0.5% to 1.5% of people 14 to 24 years of age have an eating disorder, while earlier estimates also reported that at the beginning of the nineties 30% of schoolgirls had dieted at least once and 43% had engaged in physical exercise to lose weight, 38% of University people had three or more dieting female friends and 91% had a dieting female relative. Other confirming studies are by Canals et al (14), Morandé et al (15) and Martin et al (16). Obviously, the model of thin female beauty suggested by the media on the desired weight of teen women might play a role, though the extent of its impact is not clearly quantifiable. A partial answer was delivered by Toro et al (17), who attempted to evaluate the impact of manifold social agents concerning the subjects' attitude to body shape. The findings were that the sensitivity to media advertising for slimming products and to oral and written information supporting the culture of slenderness was much higher in anorexic subjects than in the normal population, while the influence of both the behavior of dieting friends and the models suggested in the familial environment did not show differences. Thus, the study stressed the importance of the role played by the media as a socio-cultural factor for eating disorders. Another possible factor is the increasing spreading of unhealthy weight-control practices (18). In addition, a study has shown that more eating disorder symptoms and body dissatisfaction in Spain than in a different Spanish-speaking country Mexico. This suggest that the degree of influence of consumeristic culture related with eating disorders higher in southern Mediterranean Europe than in other countries of similar culture (19). A recent epidemiological survey has confirmed the significant prevalence of eating disorders in Spain, even in a peripheral region like Navarra (20).
Italy Italy has produced a large quantity of research on eating disorders. The first documented cases appeared in the late 19th century and during the first half of the 20th century. Mara Selvini-Palazzoli recounted that she observed a rapid increase of cases just after World War II, when she was resident at Milan General Hospital (21). More recently, four studies have investigated the epidemiology of eating disorders in samples recruited in the north (22), the central (23), and the south of Italy (24,25). As in Spain, the findings were of much concern and comparable to rates found in northern European countries. Surprisingly, the papers from the south of Italy reported that their prevalence rates were equal to rates found in northern
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Italy. The finding was thought as surprising enough with respect to the supposed rurality of southern Italian society. In fact, few other European countries show such an impressive disparity of development within their territory, as Italy shows between its northern and southern regions. A seminal work written by Giustino Fortunato had the appropriate and telling title: 'Le due Italie'. That in English is: 'The two Italies' (26). In that paper, Fortunato explained how disparity between northern and southern Italy concerned not only industrialization and economical prosperity, but also cultural values and societal organizational structures. He meant that a strong social middle-class and a pre-capitalistic economy were frequently present in the towns of northern Italy and Tuscany since the Middle Ages, while they were absent in the southern Kingdom of Naples. The rural economy of southern Italy produced a poor social life, in which peasants lacked a sense of autonomy, of initiative and fulfillment of their personality by means of development of competence and industry (27-32). In these modern times some aspects of those conditions still exist, although mixed with the products of the consumerist society, so that we have the so-called condition of "consumerism without development" (33,34). As with Toro in Spain, Ruggiero et al (35) studied the impact of socio-cultural determinants in Italy. They compared the presence of psychological and socio-cultural determinants of eating disorders in female teens coming from northern and southern Italian towns. The study supposed that the two parts of Italy showed a different sensitivity to the standards of female beauty proposed by the media. The explored determinants were the mass media influence in suggesting body ideals to girls, the degree of body dissatisfaction, and themes linked to self-esteem and insecurity as measured by EDI (Eating Disorder Inventory). Significant differences emerged from the comparisons. Mass media influence and body dissatisfaction were lower in the southern sample, while the sense of self-ineffectiveness, of perfectionism, and of fear of maturity were lower in the northern sample. The study concluded that southern Italian female teens would feature a different epidemiology of the socio-cultural determinants of eating disorders. Southern teens would be less sensitive to mass media body ideals and more satisfied with their aspect than their northern peers, but also more suffering of a psychological condition of lower self-esteem, higher emotional confusion, social insecurity and a fear of the future with respect to the northern teens. The emerging map was very interesting and suggested the intriguing hypothesis that, in the south, low selfesteem and high social insecurity might be powerful psychological determinants for eating disorders as body dissatisfaction is in the north. A study by Tiggemann, Verri and Scaravaggi (36) aimed to investigate body dissatisfaction and disordered eating from the different cultures Australia and Italy. Actually, Australia and Italy are similar western cultures in many ways, including frequent and obvious portrayals of thin media ideals for women, but represent different cultures with respect to language and the roles of the family, meals, and fashion. The study explored the internalization of thin ideals, fashion magazine exposure, the importance of clothes, body dissatisfaction, dieting, and possible disordered eating symptomatology. The Australian women scored higher than the Italian women on disordered eating. Contrary to prediction, clothes were rated as more important by Australian than by Italian women and fashion magazine consumption, in contrast, predicted body dissatisfaction and disordered eating only for Australian women, but not for Italian women. Thus, the study has shown a higher influence of consumeristic culture on body dissatisfaction in Australia than in Italy and had demonstrated that the same variables may play different roles in the Australian and Italian
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cultural contexts. Another study by Bagnara, Huon and Donazzolo (37) compared the Sociocultural Attitudes Towards Appearance a found a similar higher influence of fashion industry on body dissatisfaction in Australian women than in Italian women. On the other hand, Mautner, Owen and Furnham (38) compared body image disturbante in samples recruited in England, Italy and the United States of America and found a lack of true cultural differences, or general similarities among university students, might explain these results.
Greece In Greece, a finding comes from Fichter et al (39), who measured eating disorders rates and psycho-social determinants in a Greek sample of teens who migrated to Germany (hence exposed to a demanding cultural change) in comparison to control groups composed of nonmigrated German, Greek and Turkish teens. Migrated Greeks showed the highest prevalence of eating disorders, but also the lowest figure consciousness (a psychological dimension roughly belonging to the body dissatisfaction area). According to the authors, the resulting lower scores on figure consciousness (even in comparison to non-migrated Greeks) is probably due to the health screening required before obtaining permission to live in Germany. However, it is relevant that the screening did not impede the development of the highest rates of eating disorders, which is attributed by Fichter to the demanding cultural change suffered by the Greek migrated sample. In addition, Yannakoulia et al (40) and Babio et al (41) found that a significant percentage of students in this urban Mediterranean adolescent population found to have abnormal eating attitudes. This finding may be partly explained by the effect of cultural transition.
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Egypt, Morocco, Tunesia and other Arab countries There are a very few studies on eating behavior conducted in Arab countries. A study by Ghazal, Agoub, Moussaoui and Battas (42) assessed prospectively the prevalence of Bulimia Nervosa and its characteristics in a Moroccan context in a randomly selected and representative sample of students attending six secondary schools in Casablanca. A second group composed of the students of the French secondary school of Casablanca was included in the survey in order to verify the influence of socio-cultural factors. The prevalence of bulimia in the Moroccan sample was 0.8% (1.2% in female and 0.1 in male subjects). In the group of the French school, the prevalence of bulimia was 1.9% in the whole sample (3.4% among girls and no case among boys). These results are comparable to those reported recently in occidental countries and in Egypt. However, the prevalence of bulimic syndrome in the Moroccan sample was lower to those reported in countries with similar culture. The elevated prevalence of 10% reported in a Tunisian study could be explained by the composition of the sample (medical students, aged 22-28 years) and the cut-off point for the BITE was determined to be 20 without taking into account severity criteria. A research measured and compared the body dissatisfaction in populations coming from Northern European, Mediterranean, Asian and African countries and found that a population from Tunisia, a country plausibly undergoing a process of Westernization, showed an intermediate amount of
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body dissatisfaction, i.e., lower than that shown by Northern Mediterranean countries and higher than that of non-Western countries such as Ghana and Gabon (43). In conclusion, the data from Arab countries suggest that with the enormous media coverage and the globalisation of the media, cultural differences are disappearing. In order to estimate the prevalence of bulimia nervosa in the Moroccan population and to identify the risk factors, further epidemiological community-based studies using structured psychiatric interviews are required. Tlili et al (44) aimed at assessing attitudes towards body size of urban Tunisian women. A cross-sectional, population based study was conducted in a peri-urban area of the capital, Tunis with 203 women, aged 18-52 years. They were asked to associate 31 items with 1 of 6 photographic silhouettes of different body size; BMI was measured and over half of women were overweight or obese (BMI = 25kg/m2). Almost two-thirds of all women were dissatisfied with their current body size. A normal body size (BMI 20-24 kg/m2) was seen in the most positive light by Tunisian women, although some positive attributes were associated with overweight silhouettes. Obesity was seen as undesirable, associated with greediness and poor health. There was no marked preference by younger women for slimmer body sizes, as had been expected. However, there was a preference by women with higher socioeconomic status for slimmer body sizes for some items. The finding that Tunisian women did not prefer larger body sizes may suggest a preference for a slimmer norm, closer to that in Western societies. In the early 1980s, very few studies were done to address weight concern issues in the Egyptian societies. At first, Nasser (45) found no evidence for eating disorders, and then in a follow up study, Nasser (46) started to find that 3.4 % of her sample showed signs of weight concerns, dieting and eating disordered attitudes. In addition, Nasser (45, 46) found that Arab students attending London University had actually higher eating disorder rates than Arab students at Cairo University. However, contrary to the expected, the Cairo sample showed higher weight concern. The study showed that concern with body weight and shape was in existence in societies presumed to have different values in this respect. Thereby the identification with cultural norms privileging thin ideals of female beauty was thought to play a role. The observation that actual clinical cases emerged in the group more sensitive to these ideals supported the hypothesis further. According to the author, thinness is not simply an ideal of female beauty, but intuitively symbolizes a new social feminine model, which expresses the qualities of self-discipline, control, and sexual liberation combined with fashionable attractiveness. This finding may be partly explained by the effect of cultural transition. In fact, as time passed, the exposure to Western media and Western eating habits pose the risk of increased weight consciousness and disordered eating for Egyptian women. Becker and Hamburg (47) found that Egypt is experiencing the spread of the Western aesthetic ideal through the disseminating propaganda of the Western media. In addition, dietary changes now include increased exposure to American, trendy fast food. The dietary change, combined with shifting of meal times and less opportunities for physical exercise are all bound to an increase in the rate of obesity, which in turn would heighten weight consciousness and predispose women to increased risk of disordered eating patterns (48). This may be true also for Arabian areas near the Mediterranean sea. In fact, Eapen, Mabrouk and Bin-Othman (49) have found that thin body preoccupation as well as family and social factors are important in the development of abnormal eating attitudes among adolescents in this Arabian Gulf country.
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Abdollah and Main (50) examined the body image of Iranian women. As widely known, Iran government has outlawed the influx of Western media since the Islamic revolution in 1978. The findings indicated that Iranian women display evidences of eating disorders and body image concern, but these findings were not related to the exposure to Western media, given that access to Western media is difficult and illegal in Iran. In addition, Iranian women are mandated by law to wear some form of partial or full body covering while in public. The covering should reduce the emphasis on size and shape of the female body. However, the authors found that women who covered their bodies starved themselves and were preoccupied with exercising. Thus, the resulted showed that body coverage does not protect from body image concerns or eating disorders. According to the Arab Human Development Report of the United Nations Development Programme (51), the condition of women in Arab countries is still submitted to patriarchal authority and not autonomous. In spite of women’ entry in education and professional life, the question of good repute and honor has been barely affected by the major transformation that took place in the past century. In a patriarchal society were men hold total control of social, economic, politic and private life, a women’s right to personal decisions is not consented. However, it is plausible that also Arab countries are experiencing a period of initial modernization and partial exposure to media the shock of cultural change can be experienced without real migration: the continuous exposure to media images showing a brilliant, independent and assertive life-style, belonging to a world perceived by people as ‘more modern’ and ‘more real’ than actual reality, plays a powerful role in generating various maladaptative feelings. Thus, an Arab woman may pay a high price for asserting her independence. A cultural clash between patriarchal values and desire for independence and autonomy may favors familiar conflicts between the attempts of the female teens to emulate the independence of Western-oriented styles as frequently portrayed by the media, and the sometimes archaic cultural and religious values held by their parents. The clash between increased parental control and the exposure to modern values promoted by the media might induce feelings of helplessness, perceived low social rank and submissive attitudes which can be common in the emotional spectrum of eating disorders.
Israel Israel is a multicultural country with an equally diverse society, and there psychiatrists are often aware of socio-cultural factors for mental disorders. Apter et al (52) compared the eating attitudes of five Arab groups (Muslim, Druze, Bedouin, Christian, and Circassian) and five Jewish groups of schoolgirls (City, Kibbutz, Moshav, Boarding school, and young immigrants). The authors hypothesized that adolescent girls exposed to western values of femininity but residing in affluent, non-western settings would be tempted to develop an attitude toward food similar to that of anorexics. These subjects would likely suffer a cultural clash between the aim to be successfully performing at work and sexually attractive in social settings and the traditional role of the Mediterranean nurturing wife and mother. It was found that the degree of exposure to western body ideals determined a proportional degree of disordered eating attitudes. Jewish kibbutzim and Arab Bedouin population showed the highest abnormality. According to the authors, those groups were actually the more exposed
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to a cultural clash. In fact kibbutzim women embraced an ideology of sexual equality and liberation from traditional subordinate roles. Here, the clash is between the aim to become more masculine doing heavy men's work and the necessity to leave time for rearing children and taking care of their home and spouse. In addition, the kibbutz is increasingly open to media influence. The result is that the kibbutz woman has in mind both the aim of being a successfully working woman and a sexually desirable girl. Where concerning Arab Bedouin women, the authors report that in a single generation they moved from an isolated, nomadic lifestyle to a sedentary, urban settlement. The cultural clash is the non-gradual entering of formerly protected and often veiled women in universities and working occupations. On the other hand, the social change of non-Bedouin Muslim women living in villages is more gradual and less culturally traumatizing. Elizur et al (53) substantially agreed with Apter while developing their interesting model of cultural systemic therapy on the Israeli kibbutz. Another confirmation comes from a study carried out in a Kibbutz by Latzer and Shatz (54). They found that 85% of adolescent girls were dissatisfied with their figure, 63% were considering a diet, and 60% were afraid of losing control over their weight. Fifty-five percent of significant others did not think that eating disorders were more prevalent in families with fallacious attitudes about physical build and eating, and 50% thought that pubescent girls should be encouraged to diet (55). Gluck and Geliebter (56) explored the impact of religion on the development of disturbances in body image and eating behaviors. They compared body image and eating behaviors in Orthodox and Secular Jewish women and found that membership in a strict, insulated religious group such as Orthodox Judaism may protect women, to some extent, from developing body dissatisfaction and eating pathology. Latzer, Orna and Gefer (57) examined the relation between level of religiosity, grade level, self-esteem, and level of disordered eating-related psychopathology among Modem Orthodox Jewish adolescent girls in Israel and found that the level of religiosity might to some extent protect adolescent girls against developing body dissatisfaction and disordered eating pathology. A high level of religiosity is associated with less emphasis on the physical attractiveness of women and less pressure for their success and achievement outside the home (58).
Turkey Elal et al from Turkey (59) evaluated the factor structure of the EAT (eating attitudes test) in local samples and compared the results with a study completed ten years earlier (60). The findings presented two points of interest: the first was the strong presence of the "Bulimia" factor, absent in the 1989 study; the second was the emergence of a new factor, absent in the previous study. This new factor called "Ambivalence about Eating" involved both items referring to the enjoyment of eating and items referring to the avoidance of eating. According to the authors, these findings represents a conflict between traditional and new values relating to food, a kind of culture clash visible when minority groups move from a traditional to a modern society. The new aspect in this culture clash is that it is also observable in a whole region or country exposed to the invasion of new values, like in southern Italy and Turkey, rather than in selected immigrant groups. Altug et al (61) found that abnormal eating attitudes and behaviors are currently as common in Turkish University students as they are in many
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other western societies (and, increasingly, non-western societies). In their study, the authors also found that one the most important socio-cultural determinants of abnormal eating behaviors was the traditionalism of parents as perceived by the students sampled. Recent studies confirm that eating disorders are present in Turkey and show the typical “western” psychopathology: alexithymia, anxiety, obsessionality, depression and low selfesteem (62,63). In addition, an interesting study by indicated abnormal eating attitudes, low self-esteem, high social physique anxiety, and high trait anxiety in Turkish vegetarian adolescents (64).
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Cultural disconnection and the development of eating disorders It is not easy to sum up the findings of so many studies of different designs and aims. However, a common theme and direction seems to emerge from these investigations. It is the theme of the cultural clash as a possible socio-cultural determinant for eating disorders. Women may develop eating disorders not only as a result of dieting, weight and fat phobia, but also due to socio-cultural disconnection and transition (65). According to Lee (66), foodrefusal may be thought of as a common way for adolescents to express feelings of grief and anxiety due to excessive parental expectations and conflicts. Eating disorders may be linked to the appraisal of a multifaceted emotional state positioned at the crossroads of basic emotions such as fear, sadness, and anger (67) felt toward the engaging demands of the approaching adulthood and the slavery of a prolonged adolescent turmoil. Broadly speaking, it is plausible to think that both exposure to slim beauty values and stress due to cultural disconnection may be operating. The mechanism of action may be as follows: it is recognized that eating disorders grow over a ground of anxious feelings of a need for extreme self-control, and that thesis feelings are likely a product of the characteristic sense of ineffectiveness, perfectionism, negative self-evaluation and low self-esteem suffered by eating disordered people (68). These feelings may be attributed to both internal psychological factors and external social and interpersonal factors (69). Among these external factors might be the spread of new cultural representations and values. The rising of these new representations could properly be the product of social modifications occurring with the development of modern society. Modern society delivers both freedom and possibility of autonomous personal development to individuals in an unprecedented measure with respect to the past. Notwithstanding, it also produces solitude, a lack of shared rules or sense of community, and a day by day necessity of recreating values, an endless Sisyphus' labor. The anxiety of modern civilization is a strange fruit of both abundance and ambiguity of values and rules. Social life runs the risk to become a daily stock exchange of the social images of people and of their sense of individual efficiency and competence in that they are able to communicate to each other. In the special case of women, body image plays an outstanding role in the construction of the social image (70). It is not a mystery that by the early 1970s the ideal perception of feminine beauty was increasingly to be more slender and thinner. Thinness expressed a new conception of woman, a woman who must be "both beautiful and smart" (71) and strives simultaneously for career accomplishment, social acceptation and 'time-limited reproductive femininity' (72). It is no
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wonder that eating disorders remain overwhelmingly a female issue. Therefore, it can be theorized that the cultural disconnection may influence self-esteem by changing gender roles and by introducing new body ideals of slim beauty.
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The social transformation This model is applicable to the Mediterranean area, where we can notice both the penetration of new body ideals promoted by the media and the psychological confusion due to partial modernization. According to the first mechanism, some groups of people living in this area would be sufficiently influenced by the values of bodily appearance to make possible body dissatisfaction, dieting, purging, and bingeing common among female teenagers. Although often economically weak (with the exception of northern Italy and Catalonia, in Spain), the Mediterranean countries feature wealthy sectors, such as consumer-oriented communities and easy access to mass media advertisement portraying the life-style of modern fully developed affluent societies (12). The second mechanism is the psychological reaction to cultural change. In countries of partial modernization and full exposure to media the shock of cultural change can be experienced without real migration. In fact, the continuous exposure to media images showing a brilliant, independent and assertive life-style, belonging to a world perceived by people as ‘more modern’ and ‘more real’ than actual reality, plays a powerful role in generating various feelings. Such feelings could be insecurity, exclusion, meaningless life, avoidance, helplessness and low perceived social rank similar to those experienced by migrating people. It is a sort of cultural migration without physical relocation to other countries. These tensions can be easily observed in modern Italian family life. Even in the highly industrialized north of Italy, the old, rural family enterprise is often the only present social and economic agent (73). In Italy the family structure remains vital in taking economic and political initiatives, in the transition from school to work and in the long difficult road to finding a stable job (74). Secondly, the Italian family is still the almost only source of collective memory, the only instrument of transmission of knowledge and values, and the only mediator and decoder of emotional involvement (9). In addition, in less advanced Mediterranean settings with respect to the north of Italy (such as southern Italy or among Turkish and Egyptian University students and Arab Bedouins women) there is a disharmonious development of market and industrial economy and of civic society. Disharmonious means that, although an initial degree of economic and social development might generate cultural acceptation of women's emancipation and create expectations of economic independence and autonomy in young people, the insufficient development of the economy and of the social structures disappoint both these expectations. In other words, the structures of the so-called horizontal society are still weak, if not lacking. Horizontal society indicates a typical trait of advanced western societies, such as the tendency of people to join associations, clubs, and interest groups in order to pursue a certain goal or interest. This is the so-called Associative Art (75-77). Instead of the horizontal society with its forms of associative solidarity, vertical intrafamilial relationships and patronage are rather privileged in lowly urbanized Mediterranean social groups. Family seems to be the only
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actual social group, i.e. the only unity with solidarity among its members. This is the plausible consequence of a cultural situation in which the large patriarchal family has imploded into the modern nuclear family usually made up of parents and two or three children, while the new structures of the above mentioned horizontal society are still weak. What is lacking is a group of 'modern minded' adolescent peers sharing ideas with each others. Otherwise, a family may easily become an airless environment, where young people experience a too delayed entry into adulthood, with parental conflicts possibly developing following a geometrical upward progression where it may reach a unwanted dimension (10,11). Gratitude due to parents' efforts to gain the economic and social progress may be felt by young people more as a long chain of self-denial, sacrifice and personal abnegation rather than the result of social and cultural evolution (74). In fact, gratitude is a potent social feeling, capable to preserve social relations from the wear and tear of time. It has the capacity to survive the conclusion of the relation that generated it. Even when respect and affection are lost towards those who have helped us, gratitude would stop the disappearing of the relation (78). Therefore, gratitude may be a potent generator of forces that maintain Mediterranean teenagers tied to a long road of transition. All these socio-cultural determinants may converge toward a particular psychological configuration widely recognized as a major factor for the development of eating disorders (79). This psychological configuration is pathologic perfectionism, defined by Frost et al (80) as overconcern with mistakes. Pathologic perfectionists not only set high standard for themselves, but allow little latitude for mistakes, never feeling that anything is done well enough. They present strong tendencies for overly critical evaluations of their own behavior and accomplishments. In addition, pathologic perfectionists are described by most scholars as people who place considerable value on their parents' expectations and evaluations of them. It is likely that such perfectionists grew up in familial settings where love and approval were conditional. They had to perform at ever increasing levels of perfection, while any failure or mistake meant the risk of rejection by the parents and/or loss of their love and approval. This conceptualization of pathologic perfectionism and of parental criticism could be considered as a good chance to connect the cognitive and the socio-cultural streams of research of eating disorders. Anorexic and bulimic subjects apply their pathologic perfectionism to the domain of physical and social attractiveness and skills. In addition, they experience strong parental criticism, disapproval, clash and pressure in the same domain. Cultural change increases this clash. Examining Turkish University female students, Altug et al (61) noticed that perceived traditionalism of parents was related to the level of eating abnormality. The more traditional the mother was, the more disturbed were the eating habits of the students. As written by the authors, it is likely that those students living in the westernized environment of Istanbul and in its western-style universities experienced cultural criticism by highly traditional mothers. The cognitive analysis of the socio-cultural factors permit us to have a more vivid imagine of cultural disconnection and change. They are not abstract processes, they do not operate mysteriously over the minds of people, simply following a migration or an important change of social and gender roles. These determinants have to be thought rather as conceptualizations of the material interchanges among people, and in particular, among familiar members. Stringent parental control over teens and subsequent intra-familiar tensions are often the overt products of migration or of the process of cultural transition and modification. Teens exposed to cultural transition are caught between two processes: the
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desire of independence and the anger against parents exerting control (81,82) and the fear of this independence. The culture clash favors familiar conflicts between the attempts of the female teens to emulate the independence of western-oriented styles as frequently portrayed by the media, and the sometimes archaic cultural and religious values held by their parents (83). The clash between increased parental control and the exposure to modern values promoted by the media might induce feelings of helplessness, perceived low social rank and submissive attitudes which can be common in the emotional spectrum of eating disorders (84). It is also plausible that this cultural collision might increase overinvolvement and intrusive behaviors on the part of mothers toward their female teens, this being another factor predisposing adolescents to eating disorders (21).
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Conclusions To sum up, the cultural clash due to modification of old vertical social and gender roles is often traumatic and generates insecurity. Eating disorders could be thought as a sort of internal emotional experience of the cultural transformation of the Gemeinschaft into the Gesellschaft; the passage from the Community to the Association (85). In the first condition, people mainly have social obligations and dues, and social relationships are based on clan familiarity, an order not formalized in written laws. There are few options and manifold dues. In the second condition, people tend to acquire and develop a specialized competence of their own and sell it to other people according to contracts based on written and formalized rules. Subsequently, people tend to evaluate themselves and each other in terms of efficiency and competence. However, as noticed by Leopardi (75), it appears that modern, rationalistic and individualistic societies work at their best only when using a good deal of social solidarity. A solidarity based on shared values, cultural beliefs and other sentimental, non-rational 'fine illusions’ (ameni inganni). During the transition from the old patriarchal societies to the modern world, people tend to be exposed to the risk of losing old values, while the new values are still in developmental stage. Thus, traditional societies, such as those of the Mediterranean area, can try to identify themselves with updated values in a superficial way, without assimilating the attitudes and the behaviors of a horizontal society. As written above, this particular condition has been keenly called 'consumerism without development' (34,85). This article tried to demonstrate that in areas where conditions of cultural transition or partial modernization are present, such conditions create an atmosphere of psychological tension, which could contribute to rising levels of eating disorders. Such a conclusion might give us a more detailed understanding of the idea of cultural disconnection as a factor in the development of eating disorders and well expresses the contradictions generated by our difficult contemporary cultural transformation. Eating disorders could be thought of as a particular manifestation of the modern conflict between the demanding values of individual self-fulfillment (and efficiency) and the need for the development of satisfying interpersonal and horizontal relationships. To survive in our contemporary societies both a flexible management of ourselves and a refined, highly advanced, and metacognitive knowledge of our own emotional and relational functioning are required. This psychological effort can be so demanding that the temptation of returning to
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previous ideals is powerful. Unfortunately, common standards of behavior and self-definition are not available, or at least not so clearly defined as in the past. On the other hand, oppressive and inescapable personal destinies hopefully do not exist for some or most of us anymore.
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Copyright © 2011. Nova Science Publishers, Incorporated. All rights reserved. Understanding Eating Disorders: Integrating Culture, Psychology and Biology, edited by Yael Latzer, Nova Science Publishers, Incorporated, 2011.
In: Understanding Eating Disorders Editors: Yael Latzer, Joav Merrick, Daniel Stein
ISBN 978-1-61728-298-0 © 2011 Nova Science Publishers, Inc.
Chapter 9
Genetic Aspects of Anorexia Nervosa Andrea Poyastro Pinheiro, MD, PhD, Tammy L. Root, PhD and Cynthia M. Bulik11, PhD
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Department of Psychiatry, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America Anorexia nervosa is a perplexing illness with the highest mortality rate of any psychiatric disease. In this chapter, we review the genetic research on anorexia nervosa (AN). Family studies have demonstrated that anorexia nervosa is familial, and twin studies have indicated that additive genetic factors contribute to the familial aggregation. Molecular genetic research, including genomewide linkage and case control association studies, have not been successful in identifying DNA variants that are unequivocally involved in the etiology of AN. We provide a critical appraisal of these studies and discuss methodological issues that may be implicated in conflicting results. Furthermore, we discuss issues relevant to genetic research such as the importance of phenotypic refinement, the use of endophenotypes, and the implications for nosology and genetic analysis. Finally, the future of genetic research for AN is discussed in terms of genomewide association studies (GWAS) and the need for establishing large samples.
Introduction Beliefs about the etiology of anorexia nervosa (AN) have undergone remarkable change. For decades, AN was considered to be a culture-bound disorder in which family and sociocultural factors were thought to play a major role, but research suggests that genetic factors are relevant in the vulnerability to this disorder (1). AN is a complex disorder resulting from a combination of genetic and environmental factors. Accordingly, it is important for clinicians 11 Correspondence: Cynthia M Bulik, PhD, Department of Psychiatry, University of North Carolina at Chapel Hill, 101 Manning Drive, CB #7160, Chapel Hill, NC 27599-7160, United States. Tel: (919) 843 1689; Fax: (919) 843-8802; E-mail: [email protected].
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and researchers to integrate knowledge of the role of genetics as well as social, psychological, and familial factors into understanding risk for AN. AN is characterized by low body weight, intense fear of weight gain, body image distortion and amenorrhea. The prevalence of AN among females is approximately 0.9% (2) with subthreshold forms more prevalent (up to 2.4%)(3). Additionally, the mortality rate of AN is approximately 5% per decade (0.56% per year), with a standardized mortality ratio of over 10 (4, 5). In this chapter, we present a synthesis of knowledge on the genetic factors associated with the etiology of AN. Family, twin, and molecular genetic studies of AN are reviewed followed by a critical appraisal of the available literature and a brief discussion on future perspectives of genetic investigation in the eating disorders field.
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Family and twin studies Family Studies. It has been well documented that eating disorders run in families. Firstdegree relatives of individuals with AN have approximately a ten-fold greater lifetime risk of having AN than relatives of unaffected individuals (6-8). Research also suggests that there is an increased risk for any eating disorder in relatives of individuals diagnosed with AN indicating that AN and bulimia nervosa do not “breed true,” and pointing to possible shared familial vulnerabilities across eating disorders (9). Twin Studies. Although informative, family studies do not allow the separation of genetic and environmental influences on familial transmission. However, with twin studies, variance in liability to a trait can be decomposed into independent genetic and environmental influences and provide estimates of their relative magnitude (10). Because monozygotic (MZ) twins are assumed to be fundamentally genetically identical, discordance in MZ twins is likely to result from environmental influences. Conversely, differences between dizygotic (DZ) twins who share roughly 50% of the genome could be due to either genetic or environmental influences. Thus, comparing the concordance of MZ twins compared to DZ twins provides information about the relative contributions of genetic and environmental factors in the etiology of a particular disorder. Twin studies on eating disorders have demonstrated that a considerable portion of observed familial aggregation is due to additive genetic factors (i.e., heritability) (10). Twin studies have reported heritability estimates between 33% and 84% for AN (11-15) demonstrating considerable genetic effects for AN. Thus research suggests that AN appears to be moderately influenced by genetic factors
Molecular genetics Methodologies Genomewide Linkage and Candidate Gene Association Studies. Two commonly used genetic analytic approaches are genomewide linkage analysis and case control association studies. Large samples of multiplex pedigrees are required for linkage analysis studies. Anonymous
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genetic markers spread across the genome are genotyped to identify chromosomal regions harboring genes that influence the trait of interest. Candidate genes located under the linkage peaks can be explored using case control association approaches to verify whether they are in fact associated with the phenotype of interest. In case control association studies, cases who display a trait of interest are compared with controls who do not display the trait. Genetic markers or SNPs [single nucleotide polymorphisms or DNA sequence variations that occur when a single nucleotide (A, T, C, or G) in the genome sequence is altered; each individual has many single nucleotide polymorphisms (around 10 million) that together create a unique DNA pattern for that person] from a candidate gene or genes that are hypothesized to be of relevance to the phenotype are examined in all participants, and statistical analyses contrast genotype and haplotype (i.e., combination of alleles located close together on the same chromosome that are often inherited together) frequencies in cases versus controls (16). The case control association approach is suitable when there is considerable prior knowledge of the pathophysiology of a trait which could implicate specific genetic variants. Currently, genome wide association studies (GWAS) allow the assaying of several hundred thousands SNPs, enabling a comprehensive coverage of common genetic variation across the genome. Unlike case control association studies, GWAS do not represent a candidate gene approach. On the contrary, GWAS do not require a focus on biological candidate genes or a priori knowledge of the pathophysiology of the disease (17).
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Research findings in anorexia nervosa Linkage Analysis. Three linkage analyses for AN (18-20) have yielded significant results and underscored the importance of accurate phenotyping in order to reduce both phenotypic and genotypic heterogeneity. A linkage study on AN composed of 192 families with at least two affected relatives resulted in no statistically significant findings; however, when the sample was restricted to relative pairs exhibiting restricting AN, it yielded significant evidence for a susceptibility locus on chromosome 1 (20). Using the same dataset, Devlin and colleagues conducted additional linkage analyses by incorporating drive for thinness and obsessionality as covariates (19). The inclusion of these covariates revealed several regions of interest on chromosomes 1, 2, and 13. The serotonin 1D receptor (HTR1D) and the delta opioid receptor (OPRD1) located on chromosome 1 corresponded to the linkage peak identified by Grice et al (20), and represent genes previously implicated in the pathophysiology of AN (21). Further work focused on six heritable phenotypic traits relevant to eating disorders (18). Obsessionality, age at menarche, and a composite anxiety measure displayed normal distribution and familial correlation, and were suitable for quantitative linkage analysis. Conversely, some families showed highly concordant and extreme values for lifetime minimum body mass index (lowest body mass index attained during the course of illness), concern over mistakes, and food related obsessions—whereas others did not. These traits were analyzed with covariate linkage analysis, and a number of suggestive linkage signals were observed: obsessionality at 6q21, anxiety at 9p21.3, body mass index at 4q13.1, concern over mistakes at 11p11.2 and 17q25.1, and food-related obsessions at 17q25.1 and 15q26.2
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Two out of the three linkage reports for AN (19,20) based on the same sample have pointed to two statistically significant findings on chromosome 1, a 32 million base pair region from 1p36.13–1p34.2, for restricting AN (20) and a 41 million base pair region from 1q25.q– 1q41 for a composite phenotype of AN with drive for thinness and obsessionality (19). Among the 546 genes included in these genomic regions, about half are expressed in the brain. Some genes in these regions coincide with existing hypotheses of the pathophysiology of AN (i.e., HTR1D, HTR6), or are pertinent to eating behavior or satiety (i.e., the cannabinoid receptor CNR2), along with various other genes whose proteins are involved in relevant processes at the central nervous system (e.g., multiple regulator of G protein signaling family genes). Linkage studies should be interpreted judiciously given that the results may either signify areas containing genes of etiological relevance to AN, or may simply reflect false signals. Replication studies with independent samples are essential to determine the reliability of the aforementioned findings. Case-Control Association Studies. Candidate gene studies in eating disorders have mostly focused on genes encoding proteins implicated in the regulation of feeding and body weight, as well as genes involved in neurotransmitter pathways regulating eating behavior (22). Most of the publications on candidate gene studies are on small samples and consequently statistically underpowered, and not one has been replicated with adequate statistical power. Candidate gene studies not having adequate statistical power are not included in this manuscript due to the lack of robustness. Thus, for this review, a filter was applied – we recalculated power for the case-control association studies by assuming a dominant model with an allele frequency of 0.10, alpha 0.05, and a relative risk of 2.0. Using these assumptions, a minimum sample size of N = 178 cases and N = 178 controls is needed for achieving power of 80% and therefore we only selected studies that met this criteria. This filter led to the exclusion of approximately 45 published studies. Case control association studies examining serotonergic genes, dopaminergic genes, genes related to neuropeptides and feeding regulation, and brain-derived neurotrophic factor gene (BDNF) are briefly described in the next section and a summary of positive significant findings are presented in table 1. Serotonergic genes. Previous research has suggested that the serotonin pathway may play an important role in the pathophysiology of eating disorders, specifically for AN. Serotonin (5-HT) is implicated in the regulation of appetite and eating behavior, and serotonin reuptake inhibitors have been used as a treatment component of AN (23-25). Additionally, individuals who have recovered from AN have persistent 5-HT disturbances (22). These findings suggest that serotonergic dysfunction might be a biological marker for eating disorders. Further, research has shown that the psychopathological features associated with AN such as perfectionism, obsessionality and rigidity may also be associated with the serotonin pathway (22). Based on these results, genes related to serotonin (serotonin transporter and receptors) have been the focus of many genetic association studies in AN.
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Table 1. Candidate gene studies in anorexia nervosa: significant associations only. Gene Serotonin Serotonin receptor 1D HTR1D (1p36)
Catecholamine Dopamine D2 receptor DRD2 (11q23)
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Dopamine D4 receptor (11p15.5)
Neuropeptide and feeding regulation Opioid receptor delta-1 OPRD1 (1p35)
Preproghrelin gene (3p26-25)
Reference
Phenotype (N)
Polymorphism*
Pa value
Note
(21)
AN (196) Controls (98)
C1080T (rs17850242)
0.01 0.01 (genotype)
(26)
ANr (122) AN binge-purging (104) Controls (678) ANr (122) AN binge-purging (104) Controls (678)
T-1123C (rs674386)
0.026 for ANr/Controls
OR 2.63, TDT NS Controls U.S., U.K., and Germany OR 1.44
rs856510
0.02 for ANr/Controls
OR 1.51
ANr (108) AN purging (88) Controls (98)
725 bp 3_ C/T (rs6278)
0.042 (genotype PAN)
ANr (108) AN purging (88) Controls (98)
C10620T (rs1800497)
0.045 (genotype PAN)
AN (202 trios, including 111 ANr and 67 AN binge-purging) Controls (418 families, 542 daughters)
C(521)T (rs1800955)
0.009 for TDT
AN (202 trios, including 111 ANr and 67 AN binge-purging) Controls (418 families, 542 daughters)
D4 120bp repeat
0.018 for AN binge-purging
Haplo rs6275 0.038 TDT ns U.S., U.K., and Germany Haplo rs6275 0.021 (RAN); TDT ns U.S., U.K., and Germany LRS Haplo C-521T & C616G & A-809G & 120 bp tandem repeat p=0.0001; C-521T & A809G & exon III & 120 bp tandem repeat p=0.007. TDT
AN (196) Controls (98)
T8214C (rs536706)
0.045
OR 1.46, TDT NS Germany, U.K., and U.S.
AN (196) Controls (98)
G23340A (rs760589)
0.046
AN (196) Controls (98)
A47821G (rs204081)
0.01 0.03 (genotype)
AN r (131) AN binge-purging (97) BN purging type (108) Controls (300)
Leu72Met (408 C>A) (rs696217)
0.0002 (geno) 0.0410 (allele) for BN purging type/controls
OR 0.68, TDT NS Germany, U.K., and U.S. OR 0.61, TDT 0.06 Germany, U.K., and U.S.
(30)
(31)
(21)
(35)
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Andrea Poyastro Pinheiro, Tammy L. Root and Cynthia M. Bulik Table 1. (Continued).
Gene Serotonin
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Other candidate genes Brainderived neurotrophic factor BDNF (11p13–14)
Reference
Phenotype (N)
Polymorphism*
Pa value
Note
AN r (131) AN binge-purging (97) BN purging type (108) Controls (300)
Leu72Met 3056 T>C (rs2075356)
0.006 (geno) 0.0035 (allele) for BN purging type/controls
Leu72Met (408 C>A) and 3056 T>C Haplo in BN patients 0.0059, OR =1.71).
(41)
AN unclassified (98) ANr (347) AN binge purging (308) BN (389) Controls (510)
Val-66-Met (rs6265)
OR AN 1.37 (Metallele) OR ANr 1.43 (Met-allele) OR AN binge purging 1.29 (Met-allele) OR BN 1.59 (Metallele) France, Germany, Italy, Spain, and U.K.
(42)
ANr (219) AN binge purging (140)
Val-66-Met (rs6265)
0.0008 (AN versus C; genotype) 0.003 (ANr versus C; genotype) 0.012 (AN binge purging versus C; genotype) 500,000 genetic markers) with the power to identify common alleles with fairly small phenotypic effects (17). The ability to conduct a scan across the entire genome rather than specifying a priori candidate genes allows for a “hypothesis free” test (54). As with all genetic analyses it is important to keep in mind methodological issues such as design and power. The sample sizes required for adequate statistical power for GWAS vary according to the design, (e.g., single stage vs. multi-stage designs), effect size (i.e., allele frequency, genetic model, and genotypic relative risk), and the alpha value (i.e., .05/number of SNPs). It remains critical to adjust for multiplehypothesis testing when conducting GWAS (56). Given the cost of GWAS (17), researchers can find a balance between power to detect modest effects and the cost of genotyping large numbers of markers, by combining data across studies and performing multi-stage analyses
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(17,55). Although beyond the scope of this paper, the issue of population stratification (i.e., differences in allele frequency between cases and controls due to differences in ancestry, and not genetics of a disease) within the study sample must be dealt with appropriately as it can lead to false-positive results possibly outweighing true associations (17, 55). Despite its challenges, GWAS have the potential to identify many genes for common diseases and quantitative traits. Given the large samples needed to detect genotypic differences for eating disorders, and most complex disorders, collaborative data sharing of samples for the discovery of the genetic link to AN will make GWAS a realistic possibility. With this is mind, networks of collaborative GWAS encompassing distinct study samples and various phenotypes have been formed. The Wellcome Trust Case Control Consortioum (WTCCC) (57) represents the pioneering example with research efforts focused on seven complex diseases (bipolar disorder included as the only psychiatric disorder) and common controls. The Genetic Association Information Network (GAIN) is another example (58). GAIN involves six phenotypes, including attention deficit hyperactivity disorder (ADHD), major depressive disorder, schizophrenia, bipolar I disorder, diabetic nephropathy and psoriasis (58). Two GWAS have been published for AN (59, 60) and a large international consortium, the Genetic Consortium for Anorexia Nervosa (GCAN) has been established to conduct GWAS for AN (Bulik, personal communication). Analyses are currently underway.Family, twin, linkage and association studies have indicated that eating disorders run in families, largely due to the effect of genes, and that some areas of the genome may be considerably more likely to harbor risk genes. In this rapidly changing field, investigators now have the opportunity to move the field forward by creating research networks that can leverage available technology to search for genes that may be of etiological relevance to anorexia nervosa. The resulting insights could potentially shed light on important features of disease pathophysiology, such as appetite regulation, energy balance and other comorbid disorders (anxiety disorders, mood disorders, substance use and impulse control disorders). Ultimately, these advancements could assist with clinical management including tailored interventions and guide the development of innovative treatments, representing a significant evolution in mental health research.
Acknowledgments Tammy Root was supported by National Institute of Health grant T32MH076694.
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[60] Wang K, Zhang, HA, Bloss CS, Duvvuri V, Kaye W, Schork NJ, Berrettini W, Hakonarson H, The Price Foundation Collaborative Group. Genome-wide association study on common SNPs and rare CNVs in anorexia Mol Psychiatry. 2010 [e-pub]
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In: Understanding Eating Disorders Editors: Yael Latzer, Joav Merrick, Daniel Stein
ISBN 978-1-61728-298-0 © 2011 Nova Science Publishers, Inc.
Chapter 10
The Neurobiology of Eating Disorders Guido K.W. Frank 12, MD and Leah M. Jappe, BS
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Developmental Brain Research Program, Department of Psychiatry, University of Colorado at Denver and Health Sciences Center, Children's Hospital, Aurora, Colorado, United States of America Eating disorders (EDs) have been traditionally conceptualized as socio-cultural dependent syndromes. However, the typical age of onset during adolescence, the skewed gender distribution, and the association with premorbid mood and anxiety problems, likely support a strong biological influence in the etiology of these disorders. Studies using sophisticated brain imaging techniques have advanced our understanding of the pathophysiology of EDs, showing alterations in specific neurotransmitters, neuropeptides and neural systems in both ill and recovered patients. Hunger and satiety-regulating neuropeptide changes observed during the ill state of an ED appear to normalize with recovery, suggesting that these changes are the consequence of malnutrition and abnormal eating behaviors. These changes may, nevertheless, affect the outcome of the EDs and the response to treatment. Structural and resting blood flow findings also appear to be state-dependent. By contrast, neurotransmitter and receptor abnormalities persisting after recovery may contribute to ED pathogenesis. In particular, the altered serotonin (5-HT) and dopamine (DA) activity in recovered anorexia and bulimia nervosa patients vs. controls, as well as the altered activation of specific brain regions to food/eating-related anxiety provoking challenges in recovered patients, suggest these findings to be of etiological relevance. In support of this contention, the alterations in 5HT and DA activity in recovered patients have been linked with alterations in core personality traits potentially predisposing to the development of an ED, specifically harm avoidance (a behavioral correlate of anxiety) in anorexia nervosa, and the combination of anxiety, impulse and affect dysregulation, and abnormal reward experience in bulimia nervosa.
12 Correspondence: Guido KW Frank, MD, Assistant Professor in Child and Adolescent Psychiatry, Developmental Brain Research Program, Department of Psychiatry, University of Colorado at Denver and Health Sciences Center, Children's Hospital, Gary Pavilion Building B-130, 13123 East 16th Avenue, Aurora, CO 80045 United States. E-mail: [email protected].
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Introduction The eating disorders (EDs) anorexia nervosa (AN) and bulimia nervosa (BN) are severe psychiatric illnesses that involve preoccupations with weight and shape that coincide with abnormal, dysfunctional eating behaviors, and, in AN, extremely low weight(1). The fear of gaining weight and the abnormal experience of one’s own body are puzzling characteristics of these disorders, and their biologic underpinnings remain largely unexplained. Comorbid mood and anxiety problems are common in EDs and could have a direct or indirect etiologic link to EDs. In this chapter we will discuss feeding behavior in relation to biologic and psychological factors and will present biologic studies in EDs that have furthered our knowledge of mechanisms that may contribute to the pathophysiology of AN and BN.
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Clinical presentation In AN, individuals restrict food intake, present with weights below 85% of that expected for age and height, express fears of weight gain, and endorse distortions related to body size and shape, that is ‘feeling’ fat despite emaciation. The current AN diagnostic criteria require amenorrhea for three or more months. AN patients usually refuse to gain weight and do not acknowledge the severe health consequences of maintaining low body weights. A restricting (AN-R) and a binge-eating/purging (AN-B/P) type have been described (1). AN-R individuals restrict food intake and may over exercise as a means of weight control, but do not routinely engage in binge eating or purging behaviors, in contrast to the B/P subtype. Bulimia nervosa (BN) occurs in individuals who are at normal or higher than normal body weight. The disorder is characterized by recurrent episodes of uncontrolled binge eating followed by compensatory behaviors to counteract weight gain such as self-induced vomiting or laxative/diuretic abuse, as seen in the BN-purging subtype (BN-P), or fasting and over exercise only as seen in the non-purging BN subtype (BN-NP) (1). Stereotypic patterns of eating behavior are hallmark characteristics of both ED groups. AN patients severely restrict food intake, particularly fat and carbohydrates. People with AN rarely stop eating all together; rather, they restrict their caloric intake to a few hundred calories a day. They tend to have monotonous choices in food intake, eating the same things every day, often with unusual flavor combinations and ritualistic patterns. Patients with BN often after short attempts of restriction - have recurrent binge episodes, typically of sweet, high fat foods (2), where they eat large amounts of food in short time periods. Unlike simple overeating, binges are associated with lack of control over the amount consumed, and are commonly done in secrecy. ED patients do not necessarily dislike the taste of food. In fact, they appear to have more food cravings and show higher pleasantness ratings for sweet solutions compared to controls (3,4). However, the pleasant experience is altered when the taste has to be swallowed and fears of weight gain set in (5). This indicates a very strong cognitive component in food intake regulation in EDs. Comorbid mood and anxiety disorders are common in individuals diagnosed with AN and BN. Major Depressive Disorder co-occurs in up to 40% in AN and up to 80% in BN (6). Obsessive-compulsive disorder (OCD) (41%) and social phobia (20%) have been observed in both disorders, often predating the emergence of the ED symptoms (7). Both symptomatic
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and recovered AN and BN patients also report elevated levels of harm-avoidance (8), a construct reflecting anxious, avoiding traits. Individuals with AN are often highly perfectionistic, obsessional (8), and typically display inflexible thinking patterns in addition to restraint in emotional expression (9,10). BN patients tend to act more impulsively and express more novelty seeking behavior (8). Psychological and environmental factors have often been associated with the development of EDs (11). Nevertheless, although such elements are likely involved, increasing evidence suggests that biological mechanisms contribute to a greater extent to the pathogenesis of both AN and BN (1). Many demographic aspects, which are consistently seen in EDs, support the notion of a biological involvement in AN and BN pathogenesis. Ninetyfive percent of those who develop AN are females, as are 90% of those who develop BN. In addition, EDs typically emerge during adolescence (1), which is not only a time of immense social and psychological change, but also a critical period for biological development with respect to hormones, gender, and structural and neurochemical brain maturation (12). In summary, AN and BN are associated with severe disturbances of food intake and body perception, and abnormal mood and anxiety states. The skewed gender distribution observed in AN and BN, the typical age of onset during adolescence, and the relatively consistent clinical presentations suggest that biological systems are likely involved in ED pathogenesis.
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Regulation of normal feeding behavior Normal feeding behavior is modulated by cognitive, emotional and biologic factors that can all be disturbed in EDs. Food intake initially involves an appetitive phase associated with the desire to approach food that might be triggered by hunger, thirst or food remembered as pleasant. In fact, taste is often the primary reason for eating certain foods (13). The next step in the feeding cascade involves the motivation to approach food (“wanting”) (14). Following the approach and ingestion of food, there is an experience of pleasantness (“liking”) that determines the hedonic experience of a certain food (14). Based on this experience, memories are formed that associate reward experience with certain foods and environmental cues. Food ingestion is normally terminated when the individual is satiated. Various neurotransmitters and neuropeptides contribute to individual hunger and satiety experiences and the ‘feeding cascade’ described above. Dopamine and opioid neurotransmitters have been associated with the concepts of “wanting” and “liking” food, respectively (15), whereas serotonin (5-HT) has been linked to appetite regulation and satiety (8). Neuropeptide-Y (NPY) and peptide YY (PYY) are brain chemicals thought to stimulate eating behavior, particular carbohydrate intake. The peptide cholecystokinin (CCK), secreted from the gut following ingestion of food, signals a satiety signal to the brain (16). Similarly, leptin, another endogenous hormone secreted from adipose tissue, works to decrease food intake and regulate fat stores (16). Gastric releasing peptide and bombesin activity have been shown to decrease food intake in animals and humans (16). Thus, there is a multitude of mechanisms that work in concert to regulate food intake. In addition to the numerous biological mechanisms, cognitive and emotional states may also affect and regulate different aspects of eating. For instance, emotional stress has been found to increase meal size in 30% of exposed individuals and decrease meal size in 48% of
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exposed individuals. Other studies have indicated that restrained eaters, individuals preoccupied with eating and weight, as well as non-clinical samples tend to consume more food in conditions that increase fear and other negative emotions (17,18).
Neurobiological research
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Advances in technology have allowed us to examine aspects of central neural pathways related to ED pathophysiology, including those involved in taste, emotion, cognition, and reward processing. Older studies have focused on the examination of neurotransmitter metabolites in the cerebral spinal fluid (CSF), an indirect measure of central neurochemical concentration. Since then, numerous brain imaging techniques have been employed to examine receptor activity and cerebral blood flow. The evolution of neurobiologic research in EDs has focused on alterations during the ill state and after recovery in an effort to identify state versus trait related abnormalities. Many abnormalities during the ill state – particularly those in feeding-related peptides – normalize with recovery. Various structural and brain imaging blood flow findings appear to be state dependent as well. By contrast, neurotransmitter abnormalities persisting after recovery could indicate trait alterations, or, alternatively, represent a consequence of the illness. It is important to note that neuronal activity, in general, is an integration of many factors, including neuronal firing, synaptic release and re-uptake, intracellular mechanisms, and interactions with other neuronal systems. Such brain pathways are extremely complex, and simply characterizing them as over or under active is problematic. With the advent of brain imaging techniques, research is beginning to piece together the functions and relationships between brain circuits and illness-related behaviors. Nevertheless, before we can truly understand how brain functioning mediates ED psychopathology, we need to have a better understanding of the ways in which brain function determines human behavior in general, and how this is influenced by biologic and environmental factors.
Hormones and neuropetides During puberty, when stores of subcutaneous fat tissue increase in adolescent girls, there is a corresponding increase in leptin release to the hypothalamus. Increased release of gonadal hormones such as progesterone, also occurring during puberty, stimulates dopamine (DA) release (19) and 5HT receptors (20). Although the levels of gonadal hormones are low during the symptomatic state of EDs, the premorbid pubertal hormonal surge may trigger altered mood and ED behavior in individuals who are overly sensitive to these hormones. Many neuropeptides, including NPY, PYY, and CCK, are also altered in EDs. Dysregulation of these peptides, with elevated NPY in ill AN patients, and elevated PYY in BN patients during early recovery, may account for the erratic consummatory patterns during the ill state. Most of these peptides return to normal levels with recovery (16). The role of these abnormalities as potentially predisposing or as secondary to the changes associated with the ED, and their link to the ED behavior remains to be clarified. Similarly, endogenous opioids levels are low
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in ill AN and BN patients, but tend to normalize with recovery, likely indicating that such alterations are consequences, not causes, of malnutrition and aberrant eating behavior.
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Neurotransmitters Serotonin (5-HT) modulates appetite, motor activity, mood, obsessional behaviors, impulse control, and reward. Most of the cell bodies of 5-HT neurons are located in the raphe nuclei of the midline brainstem and project to cortical, striatal, and limbic regions (8). Early studies have looked at CSF 5-HT metabolites to approximate 5HT neural activity (8). Ill AN women show reduced concentrations of CSF 5-HIAA, the major 5-HT brain metabolite, compared to healthy controls (21). In order to determine whether the disturbances in 5-HT function can potentially predispose to an ED, CSF studies have also been carried out in recovered patients. In these studies, recovered AN subjects have shown higher than normal concentrations of CSF 5–HIAA, that is about 50% greater than CSF 5-HIAA levels found in the ill state (21). Symptomatic BN individuals have normal CSF 5-HIAA levels, but the more severely affected patients may present with lower CSF 5-HIAA levels (22). In contrast, recovered BN patients show elevated CSF 5–HIAA (21), being similar in this respect to recovered AN patients. These findings suggest that abnormally high 5HT brain levels could be considered a trait marker for both AN and BN. 5-HT neuronal pathways play a role in the expression of anxiety and fear, obsessional behaviors, and depression (8,23,24). It has been consistently postulated that increased 5-HT activity is inhibitory of behavior, likely related to harm-avoidance traits (8). In AN, it is possible that intrinsically high 5-HT activity contributes to such harm-avoidant, anxious traits. If this is the case, then by depleting tryptophan, the dietary precursor of 5-HT (25), food restriction may serve to produce anxiolytic effects for individuals potentially predisposed to an ED. In support of this contention, several studies have found that the depletion of tryptophan may reduce dysphoric mood in both ill and recovered AN subjects (8), suggesting food reduction to possess a “self-medicating” effect. Dopamine (DA) neurotransmission plays a key role in movement, attention, learning, and reward processing, and may also be related to novelty seeking (26). The cell bodies of DA neurons originate in the ventral tegmental area and substantia nigra of the midbrain and project to three main regions – the striatum, tubero-infundibular area, and prefrontal cortex. DA CSF studies have indicated that underweight and recovered AN-R patients have reduced concentrations of CSF homovanillic acid (HVA), the major metabolite of DA, compared to controls (27). By contrast, BN patients of normal weight appear to have normal HVA levels, although these levels may decrease in proportion to binge frequency (22). Phenotypically, AN-R patients have stereotyped hyperactive motor behaviors, anhedonic, restrictive personalities, reduced novelty seeking, and a lower incidence of alcohol and drug use in comparison to BN patients. The latter tend to be more impulsive and show increased novelty seeking. The low DA levels in ill and recovered AN patients could be related to altered reward response to food stimuli with low motivation to approach food, as well as to difficulties with behavioral change during treatment, resulting from impaired cognitive flexibility. By contrast, the role of DA in BN is still largely unknown.
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The DA and 5HT systems have intimate relationships. Thus, the differences in 5-HT1A and 5-HT2A receptor activity may play a role in the modulation of DA neurotransmission (28). In addition, 5-HT2A receptors are located in the substantia nigra and ventral tegmentum, regions rich with DA neurons (29). A different balance between DA and 5HT activity has been postulated to occur in AN vs. BN patients, potentially contributing to the differences in overt expression in ill patients. It is not clear yet whether the DA and 5HT neurotransmitter abnormalities are premorbid vulnerabilities, or the consequence of the ED. If the latter is the case, then the functionality changes occurring in these neurotransmitters during the course of the illness might contribute to ED-related behavioral disturbances and treatment resistance, since both DA and 5HT modulate mood and reward pathways in the brain (26).
Neuroimaging
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The past two decades have seen the introduction of advanced imaging tools that improve the understanding of the structure and function of the brain. Such techniques can be used to characterize complex neurobiologic systems in living humans and their relationship to behavior. In the field of EDs, the information gathered using imaging techniques, from individuals in both ill and recovered states, has rapidly advanced our knowledge of the pathophysiology of EDs. Several imaging techniques are currently used in psychiatric research, including single photon emission computed tomography (SPECT), magnetic resonance spectroscopy (MRS), positron emission tomography (PET), and magnetic resonance imaging (MRI). SPECT and PET both use radioactive ligands to examine neuroreceptors as well as blood flow and glucose metabolism, whereas MRS examines the chemical composition of bodily tissues. MRI, does not use radioactive tracers and examines either brain structure or, when used repeatedly in functional MRI (fMRI), brain blood flow to estimate neural activity.
Structural and resting-state metabolic neuroimaging in AN and BN Several structural brain imaging studies using MRI found reduced gray and white matter in symptomatic AN and BN patients. Recent data indicate that these abnormalities are state dependent, since they mostly return to normal levels with recovery (30). In addition, CastroFormieles, et al. (31), using MRS to examine prefrontal cortex neuro-chemistry, have reported a lower ratio of N-acetyl-aspartate (a precursor of neuronal peptides required for brain myelin synthesis) to choline (required for cell membrane integrity and neurotransmitter activity), a lower ratio of glutamate (an excitatory neurotransmitter) to glutamine (converted from glutamate, constituent of proteins), and lower myo-Inositol concentrations (cell membrane constituent and secondary messenger) in symptomatic AN patients vs. controls. Using PET, various groups (32) have reported resting-state hypo-perfusion in frontal, parietal, and temporal brain regions in AN patients than in controls. These MRS and PET findings during the ill state reflect neuronal membrane damage and reduced hemodynamic brain
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activity in AN that are likely secondary to malnutrition. Their relationship to the disease pathology remains unclear (32).
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Functional task-activation brain imaging studies: AN Functional task-activation brain imaging studies in AN patients have used either visual or taste stimuli to trigger anxiety. Studies using pictures of food have found greater activation of frontal, temporal (including the amygdala), and cingulate cortices in AN patients in comparison to controls (32). The amygdala, in particular, has been implicated in fear conditioning (33), likely playing an important role in the predisposition to AN with respect to the rapid development of weight phobia in these patients. In a cross sectional comparison of symptomatic and recovered AN patients (34), pictures of food have activated medial prefrontal and anterior cingulate regions in both patient groups to a greater extent than in controls, but lateral prefrontal regions have been activated only in recovered AN patients. According to these studies, the exaggerated medial prefrontal and anterior cingulate activation could be considered a premorbid trait vulnerability in AN patients, whose heightened anxiety is mediated by these brain regions (34). A different picture emerges in studies assessing taste stimuli. Wagner et al (35), using a 10% sucrose solution and water (35), found decreased activation of the anterior cingulate cortex, insula, and striatum to both taste stimuli in recovered AN-R patients in comparison to controls. Furthermore, self-report of pleasantness of the taste stimulus and activation of these brain regions have been found to correlate only in controls. A confirmation study (Frank et al, unpublished data) has similarly found reduced brain response to sucrose in recovered AN patients compared to controls, and a lack of a correlation of pleasantness rating for sucrose with insular activation. These studies suggest a possible difference in the processing of tastes between AN-R and control women. In this respect, the insula is implicated in both early processing of sensory stimuli and reward associations (36), whereas the anterior cingulate cortex is implicated in reward anticipation and executive function (37). The differences in the findings of studies using visual food stimuli (34) (greater activation of the anterior cingulate cortex), and actual gustatory stimuli (35) (decreased activation of the anterior cingulate cortex) may reflect differential activation processes in conditions of stimulus saliency and anticipation versus actual stimulus-receipt processing.
Neuro-receptor imaging studies in AN Neuro-receptor imaging studies assess the “functional availability” of different receptors, for instance 5HT or DA receptors, in the brain. The 5HT1A and 5HT2A receptors are likely involved in the modulation of mood, feeding, impulse control, sleep, and anxiety. In studies using PET and the radioligand [11C]WAY, 5HT1A receptor binding has been found elevated across most brain regions in a mixed group of symptomatic AN-R and AN-B/P patients, as well as in recovered AN-B/P patients, in comparison to controls (38). By contrast, recovered AN-R patients have shown normal brain 5HT1A binding (38). In addition, reduced 5HT2A
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binding has been found in the frontal, parietal, and occipital cortices in both ill and recovered AN women of both subtypes vs. control women (39). In summary, after recovery, 5HT1A receptor binding seems to differentiate the two AN subtypes, whereas 5HT2A receptor binding is reduced in various brain regions of both restricting and B/P AN patients. Some progress has been made in the attempts to tie serotonergic and dopaminergic neuroreceptor abnormalities to ED-related behavior. Harm avoidance has been positively correlated with mesial temporal cortex (amygdala and hippocampus regions) 5HT2A binding in recovered AN-B/P patients, and with mesial temporal cortex 5HT1A binding in recovered AN-R patients. The possibility that 5HT receptor activity, together with other neurotransmitter systems, modulates complex behaviors such as harm avoidance in recovered AN patients may support its role in the predisposition to AN. Recently, we have found increased DA-D2/D3 receptor binding ([11C]raclopride, PET) in the anteroventral striatum of a group of recovered AN-R and AN-B/P patients (32). This increase in DA receptor activity is likely consistent with the reduction in CSF DA metabolites found in older studies (27). Interestingly, reduced DA-D2/D3 receptor binding has been found in obese subjects (40), suggesting that DA-D2/D3 receptor binding could be a biologic correlate of the tendency to either restrict food or overeat.
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Functional task-activation brain imaging studies: BN BN subjects show increased hedonic ratings for sweet stimuli compared to controls (4) likely reflecting altered centrally processed taste perception. An fMRI study of our group in ten recovered BN subjects (41), using glucose challenge, has found reduced anterior cingulate activity compared to six healthy control women. As the anterior cingulate cortex is involved in the anticipation of reward (42), its reduced activity in recovered BN subjects might suggest the likelihood of a decreased neural response to reward expectation of sweet stimuli. Nevertheless, more specific reward-related tasks have to be undertaken to verify this preliminary finding. From a different perspective, Uher et al (43), also using fMRI, have shown reduced occipital/parietal activation in response to line drawing pictures of body shapes (thin, normal, overweight) in BN patients vs. controls, similar to those reported in AN subjects. This might implicate a common neural network involving the parietal cortex in different ED types.
Receptor imaging studies in BN Receptor imaging studies (44) using PET and the radioligand [18F]altanserin have shown reduced orbitofrontal 5HT2A receptor binding in recovered BN vs. control women. In that study, BN women have failed to show the age related 5HT2A binding decline that is found in normal controls (44). This finding is suggests a scarring effect of the illness. A number of studies have implicated the orbitofrontal cortex in inhibitory processes (45) and in the representation of food-related affective values (46). Thus, reduced orbitofrontal activity may contribute to behavioral disturbances characteristic of BN, such as impulsivity and affective
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dysregulation (47). No specific tasks, however, have been applied in conjunction with 5HT receptor binding assessments to better understand the implications of a behavioral– neuroreceptor relationship. In other neuroreceptor studies, symptomatic BN patients showed reduced 5HT transporter binding in the thalamus and hypothalamus (48), but increased 5HT1A receptor binding (49), primarily in the medial prefrontal cortex, the posterior cingulate and angular gyri of the parietal cortex. The dynamics between 5HT receptor expression and synaptic 5HT are still not well understood. Reduced 5HT2A binding in recovered BN subjects may be related to higher levels of endogenous 5HT in the synaptic cleft, and/or a down-regulation of the 5HT2A receptor. Along the same lines, increased 5HT1A receptor binding during the symptomatic state of BN may reflect reduced 5HT synaptic level and/or an up-regulation of the 5HT1A receptor (22,50). In addition, reduced 5HT transporter availability in ill BN patients may be an adaptation in response to lowered 5HT concentrations in the pre-morbid state. Of interest, selective 5HT reuptake inhibitors (SSRIs) are effective in the treatment of BN, but symptomatic BN patients require higher SSRI doses compared to patients with other psychiatric disorders, like depression (8). This relative resistance to SSRI treatment may be related to an up-regulation of the 5HT1A autoreceptors, which inhibit 5HT release.
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Conclusions The typical age of onset during adolescence and the skewed gender distribution suggest a strong biological influence in the etiology of EDs. Many neurobiological factors contribute to the disturbances observed in feeding behavior, emotional regulation, and cognitive processing characteristic of EDs. Moreover, disturbances in specific neurotransmitters, neuropeptides and neural systems may predispose certain individuals to develop an ED. Nevertheless, it is still difficult to ascertain which biological factors are premorbid traits, which are state dependent traits existing only in symptomatic patients, and which are considered a consequence of the illness, potentially affecting outcome and the response to treatment. Hunger and satiety regulating neuropeptide changes observed during the ill state of an ED appear to normalize with recovery, suggesting these changes to be the consequence of malnutrition and abnormal eating behaviors. Structural and resting blood flow findings also appear to be state-related, whereas neurotransmitter and receptor abnormalities persisting after recovery, may contribute to ED pathogenesis. In particular, the finding of intrinsically altered levels of 5-HT and DA activity in recovered AN and BN patients may contribute to core characteristics of these disorders such as harm avoidance, anxiety and obsessional behaviors in AN, and novelty seeking, impulsivity, negative emotionality, and abnormal reward experience in BN. We are entering an exciting time when neuroimaging can be combined with other biological approaches, particularly genetics and cognitive neuroscience, to unravel pathophysiological mechanisms of disease and identify new treatment targets. Considerable research is still needed to gain a sound understanding of the role of biological, emotional, and cognitive factors and their interactions in feeding, fear, body image, and reward processing in EDs. Moreover, ongoing research in these domains has the potential to provide new treatment options that would improve the often unfavorable outcome of these debilitating disorders.
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[41] Frank GK, Wagner A, Achenbach S, McConaha C, Skovira K, Aizenstein H, et al. Altered brain activity in women recovered from bulimic-type eating disorders after a glucose challenge: A pilot study. Int J Eat Disord 2006;39:76-9. [42] Richmond BJ, Liu Z, Shidara M. Neuroscience: Predicting future rewards. Science 2003;301:179-80. [43] Uher R, Murphy T, Friederich HC, Dalgleish T, Brammer MJ, Giampietro V, et al. Functional neuroanatomy of body shape perception in healthy and eating-disordered women. Biol Psychiatry 2005;58:990-7. [44] Kaye WH, Frank GK, Meltzer CC, Price JC, McConaha CW, Crossan PJ, et al. Altered serotonin 2A receptor activity in women who have recovered from bulimia nervosa. Am J Psychiatry 2001;158:1152-5. [45] Robbins TW. Chemistry of the mind: Neurochemical modulation of prefrontal cortical function. J Comp Neurol 2005;493:140-6. [46] Kringelbach ML, O'Doherty J, Rolls ET, Andrews C. Activation of the human orbitofrontal cortex to a liquid food stimulus is correlated with its subjective pleasantness. Cereb Cortex. 2003;13:1064-71. [47] Steiger H, Young SN, Kin NM, Koerner N, Israel M, Lageix P, et al. Implications of impulsive and affective symptoms for serotonin function in bulimia nervosa. Psychol Med 2001;31:85-95. [48] Tauscher J, Pirker W, Willeit M, de Zwaan M, Bailer U, Neumeister A, et al. [123I] betaCIT and single photon emission computed tomography reveal reduced brain serotonin transporter availability in bulimia nervosa. Biol Psychiatry 2001;49:326-32. [49] Tiihonen J, Keski-Rahkonen A, Lopponen M, Muhonen M, Kajander J, Allonen T, et al. Brain serotonin 1A receptor binding in bulimia nervosa. Biol Psychiatry 2004;55:871-873. [50] Kaye WH, Greeno CG, Moss H, Fernstrom J, Fernstrom M, Lilenfeld LR, et al. Alterations in serotonin activity and psychiatric symptoms after recovery from bulimia nervosa. Arch Gen Psychiatry 1998;55:927-35.
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In: Understanding Eating Disorders Editors: Yael Latzer, Joav Merrick, Daniel Stein
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Chapter 11
Hemispheric Asymmetry in Eating Disorders Zohar Eviatar13, PhD1,2 and Yael Latzer, PhD3,4
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The association between eating disorders (ED) and dysfunction of the central nervous system has been explored since the early 1970s. These studies have focused on structural, functional and behavioral differences between women who suffer from various EDs and healthy women. The results have been equivocal, both in terms of general brain functioning, and more specifically, in terms of hemispheric differences. This chapter reviews this research, and attempts to highlight some of the systematicity that has been reported. We propose an integrative framework in which to explore the functioning of brain networks in EDs.
Introduction Historically, clinical studies of eating disorders (ED) have tended to come from family therapy theorists (1), who focused on family relations, communication and structure or mother-child relations (2). However, for almost 40 years, associations between eating disorders and dysfunction of the central nervous system have also been explored. These studies have had a wide focus, from those exploring brain distributions of gustatory chemicals and functions, to those exploring deficits in the representation of self. This wide range reflects the intimate relationship between very different issues relevant to eating behaviors: satiety and interoception in general, social cognition, and psychological well being. Thus it is not 13 Correspondence: Professor Zohar Eviatar, Institute for Information Processing and Decision Making and the Department of Psychology, Haifa University, Mount Carmel, IL-31905, Haifa, Israel. E-mail: [email protected]. 1 Institute of Information Processing and Decision Making, Haifa University, 2Department of Psychology, Haifa University 3 Faculty of Social Welfare and Health Sciences, Haifa University and 4Eating Disorders Clinic, Psychiatric Division, Rambam Medical Center, Haifa, Israel
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surprising that clear cut findings have yet to be reported. In a recent review of imaging studies, Hurley and Taber (3) reported a large variance in brain regions showing group differences between patients and controls. One of the key points they make is the wide range and complexity of circuit abnormalities that can produce the same behavioral symptoms.
Structural studies Structural studies of anorexia nervosa (AN) indicate general brain atrophy, often identified as cerebral spinal fluid spaces enlargement (4-6), reduction in size of the pituitary gland (7,8), cerebellar atrophy (9) and subcortical hyperintense changes on T2 MRI images (10), which only in part are reversible after weight restoration. Structural studies of bulimia nervosa (BN) report cerebral atrophy and enlarged ventricles with loss of brain tissue water, potentially attributable to changes in vascular permeability secondary to release of vasopressin (11,12). Lesion studies (13) have reported that ED symptoms resulted from both subcortical and cortical hemispheric lesions, with the latter being primarily localized in the right frontal and temporal lobes. The frontal right hemisphere (RH) has been specifically implicated in binge eating related to dementia (14) and in Gourmand Syndrome (15,16).
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Functional studies Functional studies of AN (SPECT, PET and fMRI) show the prefrontal cortex as a critical region for the integration of food-related information, and a diffuse bilateral frontal and parietal hypo-perfusion, which is more dominant in the left hemisphere (LH). In particular, SPECT revealed an asymmetric pattern of reduced perfusion, especially in the left sylvian cortex and temporal, parietal, and occipital cortices. Reduced regional cerebral blood flow was also noted in the left cerebellar hemisphere. Functional studies in BN revealed increased cortical activity in BN patients before eating, especially in the left inferior frontal regions (17). Karhunen et al [18] suggested that frontal and prefrontal regions of the LH play a role in binge eating in humans. Hagman et al (19) found that control subjects have higher glucose metabolism in the RH than the left, but that patients with BN have lost this normal right activation in some areas, whereas basal ganglia activity was maintained. This is in contrast to patients with depression, who retained normal right activation but had decreased glucose metabolism in the basal ganglia. Comparing PET scans of eight bulimics and eight controls, Wu et al (20) found that metabolic rate during the performance of a visual vigilance task was higher in the RH for controls, but not for bulimics. This suggests that bulimics fail to show the normal asymmetrical metabolic rate associated with vigilance, but they do not demonstrate changes in metabolism in basal ganglia associated with depression. The results indicate differential involvement of neuronal circuits associated with AN, BN and depression. More specifically, they may suggest variable differential hemispheric dysfunction in ED as compared to controls. Differences between AN patients and healthy controls tend to be found in the LH, whereas the results with BN patients are more variable.
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Behavioral studies Behavioral studies using neuropsychological tests have also reported equivocal findings in terms of differences between ED patients and control participants (21). The general findings show that verbal functions and learning capability are usually preserved. In some studies, AN patients present slowness in psychomotor skills that contributes to impaired performance in tests such as the Digit-Symbol. Both AN and BN patients show an attention deficit to diseasespecific stimuli (usually concerning body weight). AN patients show normal performance in memory skills most of the time (22), but visuo-spatial and visuo- constructive skills are probably impaired. Mixed results have been found for executive functions (23). It is clear that more research is needed to assess these deficits. Thus, the hypothesis that ED involves anomalous hemispheric organization receives mixed support from studies using neuropsychological tests and from neuroimaging studies. There have been a few studies that directly examine hemispheric involvement in ED, most focus on AN. Two studies have looked at body image processing of one's own and other's bodies. Smeets and Kosslyn (24) used a divided visual field paradigm in which AN women and thin healthy controls judged the fatness of distorted photographs of their own and of an actress’s body. The dependent measure was the proportion of distorted images that the women judged as equal to their own body. The control participants had a bias (approximately 60%) to judge thinner stimuli as equal to their body representation, and showed this same bias to stimuli presented in both visual fields. The AN women showed a different pattern: to stimuli presented directly to the RH in the left visual field (LVF), they showed no bias, e.g., their errors were evenly distributed between fatter and thinner distortions of their own body. However, when stimuli were presented in the RVF (directly to the LH), they showed the opposite bias than the controls: approximately 70% of their errors were towards judging fatter distortions as equal to their own body. These errors were faster than the same errors in the LVF. Interestingly, this pattern was shown by women who had had AN in the past, and were in remission, the participants who were in the active stage of the disease showed this biased error pattern in both visual fields. In addition, the AN participants did not show hemispheric asymmetry in judging someone else's body, only their own body. These findings converge with the report of Sachdev et al (25) of an fMRI study in which AN and healthy controls viewed images of their own or another person's body. They report that AN women show reduced activations in response to their own body image in both hemispheres, whereas their responses to another person's body was the same as that of the controls. These results suggest that in the active phase of the disease, AN women show different patterns of brain functioning from controls in both hemispheres, whereas when in remission, this difference is found in the LH, not in the RH. It is not clear yet whether this is also the case in women with BN, however there is evidence that negative aspects of body image are related to regions in both hemispheres in healthy women. Shirao et al. [26] presented healthy young women with neutral or unpleasant words, where the unpleasant words all related to body image (obesity, stumpy, overweight). fMRI images showed that the left amygdala and the right parahippocampal gyrus were activated in the unpleasant condition, and that the degree of this activation was correlated with scores on the EDI (Eating Disorders Inventory).
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General or specific deficits All of the studies described above used stimuli that are specifically relevant to ED – either body shape stimuli, or words related to food and weight. Even more specifically, several studies reveal that AN women process only their own body in an abnormal manner. These findings suggest complex relations between the content of the stimuli and the manner in which it is processed. In this context, studies that use disease neutral stimuli (not related to body image or food) can be especially useful, as they can reveal more general differences in brain functioning. In a comprehensive study that examined disease neutral neuropsychological functions in AN adolescent women before and after weight gain, Bradley et al (27) used electrophysiological indexes (N400 and P300) to measure brain states while participants performed a verbal and a nonverbal task. The results again suggest differences between AN participants and controls in both hemispheres. The latency of N400 showed a Group X Task interaction, with AN participants evincing longer latencies on the nonverbal task, but not differing from the controls on the verbal task. For P300, the pattern was the opposite: latencies in the nonverbal task were the same in the two groups, but AN had significantly longer latencies in the verbal task. Thus, different aspects of the verbal and nonverbal tasks differed between the groups. Amplitude measures showed a Group X Task X Hemisphere interaction that was due to the controls showing larger amplitudes over the LH for the verbal task and larger amplitudes over the RH for the nonverbal task. The AN participants showed no significant differences between the hemispheres in either task, with the small differences they did evince going in the opposite direction. This study also reported a correlation between BMI and N400 amplitude in the LH for the verbal task, and between the BMI and P300 amplitude in the RH for the nonverbal task. Thus, nutritional state, lower BMI, was associated with lower LH response to the verbal task and lower RH response to the nonverbal task. In addition, the Drive for Thinness subscale on the EDI, and the measure of depression, the BDI, correlated negatively with P300 amplitude over the LH for the nonverbal task—that is, higher scores in these tests were related to lower amplitudes in the hemisphere not specialized for the task. These results are especially interesting in the context of a network view of brain functioning. That is, even though they do not show an overall asymmetry, women with more severe symptoms evinced lower indexes of LH involvement in the nonverbal task, suggesting different functional architecture in the AN women than in the controls. Three studies in our lab have examined hemispheric functioning when participants with ED processed disease neutral stimuli. Eviatar, Latzer and Viksman (28) reported that women with AN did not show an expected advantage for linguistic stimuli presented to the right visual field (RVFA), while they did show an expected left visual field advantage (LVFA) for a spatial task. Women with BN showed the opposite pattern: a RVFA for a language task, but not the expected LVFA in the spatial task. We suggested then that AN women may differ from healthy women primarily in terms of LH processing, while BN women may have a deficit in RH processing. This hypothesis was partially supported by Hason et al (29), who found that women with ED made more errors than healthy women in a neutral size estimation task (the stimuli were bargraphs). Most interestingly, there was a progression of deficit in this sample, where AN women who restrict eating (AN-R) showed the worst performance and were significantly worse that both BN women and controls, AN women who purged (AN-P),
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were similar both to the AN-R and to the BN women, but were still significantly different from the control group. Finally, BN women were only marginally different from the control group. This effect was still apparent when both BMI and scores on the Beck Depression Inventory (BDI) were entered as covariates. Overall, we found the expected left visual field advantage, reflecting RH specialization for this task. However, this effect was largest in the control group, and was not evident at all in the two groups of women who purged (AN-P and BN). The hypothesis that there is some RH deficit in BN was supported, as this group differed from the control group in the LVF, not in the RVF. Our third study (30) revealed that patients with ED evince less efficient hemispheric integration than a control group in an emotion recognition task. We asked participants to perform two tasks: a face matching task and an emotion matching task. In both tasks pairs of faces are presented in three conditions: both in the left visual field (LVF, directly to the right hemisphere), both in the right visual field (RVF, directly to the left hemisphere), or one in each visual field (BVF). The BVF condition allowed us to assess interhemispheric transfer, because a correct response can only result from comparison of information initially presented to different hemispheres. It has been shown that performance of complex tasks benefits from division of labor between the hemispheres (31). The stimuli were from the set of Ekman and Friesen (32), showing happy or sad/angry emotions. In the identity matching task the participants were asked to determine whether the two faces belong to the same person (irrespective of the emotion), whereas in the emotion matching task they were asked to determine if the people in the pictures are showing the same emotion. The faces in figure 1 represent the conditions requiring different responses in the two tasks: The emotion matching task is more difficult, with all participants evincing longer RTs and more errors than in the identity matching task. We examined the degree to which bilateral presentation resulted in better performance in the two tasks. As shown in figure 2, dividing the input between the hemispheres by presenting each stimulus to a different visual field in the emotion matching task resulted in much improved performance in the control group, to the extent that performance became as good as in the easier identity matching task. None of the ED groups show this pattern to the same extent.
Figure1. Examples of stimuli in the face matching task. DFSE=Different Face Same Emotions; SFDE=Same Face Different Emotion.
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For both anorexic and bulimic purgers, the difference between the tasks was still significant in the BVF, whereas for the restricting anorexics, it approached significance. We interpret this finding as suggesting that hemispheric cooperation may be less efficient in women with ED than in healthy women.
Figure 2. Error scores on the identity and emotion matching tasks. LVF=left visual field, RVF=right visual field, BVF=bilateral visual fields. The BVF condition required interhemispheric interaction and allows hemispheric division of labor. This division of labor is more efficient in the control participants than in any of the clinical groups.
Social cognition and eating disorders Clinical studies of social behaviors in brain damaged patients (33,34) and developmental studies (35) have suggested that the RH is most implicated in deficits and in development of complex social understanding. However, imaging studies of social cognition have proposed a widespread network of bilateral brain regions that are involved (36), while recent models of emotional face processing also suggested that there is a widespread network involved, including both hemispheres (37). In addition, patients with unilateral damage to both hemispheres evince deficits in tasks requiring theory of mind (ToM) (38). Thus, the data suggest that the integrity of both hemispheres, and probably interhemispheric integration, are necessary for normal social cognition. Only few studies of ToM abilities in women with ED have been done – and the majority examined women with AN. The results are mixed. Gillberg et al (39) found similar traits in cognitive style among people with autistic spectrum disorders and women with AN. However, Tchanturia et al (40) claimed that women with AN showed decreased ability both
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in ToM and control tasks, and suggest that these results do not confirm a specific deficiency in ToM in ED patients, but rather a more basic, general deficiency.
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Comorbidity and hemispheric functions Obsessive compulsive disorder (OCD), depression and alexithymia have been shown to be co-morbid with eating disorders. Andreason et al (41) tried to establish whether functional links could be made between glucose metabolism and symptoms of depression, OCD, and BN. The results showed that lower glucose metabolism in the left anterolateral prefrontal lobe correlated with depressive symptoms observed in bulimia, but that in the orbitofrontal region, glucose metabolism of BN patients was not greater than that of the control group and did not correlate with greater OCD symptoms. All of these disorders have been related to anomalous hemispheric balance as compared to controls. Different paradigms have suggested that the balance of hemispheric functioning is different in these populations than in controls, and that these relationships are complex. For example, Saxena et al (42) performed a metabolic imaging study on nondepressed patients suffering from OCD, and reported that those who responded to SRI medication showed decreases of metabolism in the right frontal lobe. Denys et al (43) report that dopamine receptor binding is lower in the left caudate in unmedicated patients with OCD than in controls, and also, that an interhemispehric difference was seen in the patient sample, not in the controls. Electrophysiological measures reveal higher frequencies of slow wave bands and lower frequencies of alpha activity at predominantly fronto-temporal regions, as compared with controls, and most interestingly for us, this pattern is stronger in female than in male patients (44). Bruder et al (45) used the same type of paradigm with electrophysiological imaging and showed that depressed patients who did not respond to treatment with fluoxetine had significantly less alpha suppression over the right frontal lobe than over the left frontal lobe. In addition, the patients who did respond to medication in this study showed a behavioral performance asymmetry favoring the left hemisphere. Gotlib, Ranganathand, and Rosenfeld (46) also reported that currently depressed and previously depressed participants reveal left frontal hypo-activation (as measured by alpha suppression), in comparison to never depressed participants. This result is especially interesting, as Silva et al (47) have reported an identical result with a nonclinical group of restrained eaters. These authors proposed a diathesis model of increased vulnerability to eating disorders that is related to increased right frontal activity. In a recent study, Rothschild, Eviatar and Shamaia (53) reported that women with ED who purge (AN-P and BN) reveal lower ability to infer causality in the context of interpersonal relationships, and that this deficit is predicted specifically by ED symptoms, not by depression. Alexithymic individuals are characterized by a deficit in their ability to identify and express emotions. This symptom has been related both to right hemisphere dysfunction and to lowered interhemispheric communication (48). Several studies have reported elevated rates of alexithymia among anorexic (49,50) as well as bulimic patients (51). Corcos et al (52) reported that alexithymia varies with depression in both AN and BN women.
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Thus, although comorbidity of ED with a large number of other disorders is frequent, it may be that there is also a specific relationship between ED and social cognition. Models of social cognition include bilateral regions, such that deficits in social cognition both with and without EDs may be mediated by deficits in hemispheric balance and connectivity.
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Summary and an Attempt at Integration As was noted above, when women with ED were tested with disease –specific stimuli, such as images of their own or other's bodies, they tended to respond differently only to images of themselves. When the stimuli were pictures of other people, their responses were not different from those of healthy women. This raises the question of the specificity of the underlying deficit: Is it a deficit in the representation of body image, or is it a deficit in the representation of self? To our knowledge, the deficit in the representation of the self in EDs has been predominantly studied via psychodynamic paradigms (but see Abbat-Daga et al (54), who reported that low self directedness predicted the intensity of vomiting in BN (54) and age of onset of AN (55)). Of relevance to the research reviewed here, a growing number of studies report a right hemisphere specialization for the recognition of own body parts, face, and voice (56-58). Thus, it may be that a deficiency in RH functioning, or in inter and intra-hemispheric connectivity underlies this deficit. We suggest that there is a lower level of connectivity in the brains of ED women than in the brains of healthy women. Lower correlations between brain regions has previously been reported in people with autistic spectrum disorders (59), specifically with face processing. This result has been interpreted as reflecting lower coherence in the brains of autistic individuals and is similar to that of Hason et al (30) described above. The hypothesis that normal behavior arises from specific networks that function synchronously, converges with the complexity of symptoms in both autism and EDs. We suggest that ED symptoms arise as a result of insufficient communication and integration among brain regions. This hypothesis converges with the recent model proposed by Nunn et al (60). These authors suggested that the varied symptoms of AN may result from dysfunction in the insula, arguing that such dysfunction can explain much of the variation in both imaging and behavioral studies. They suggested that the inconsistent lateralization patterns that have been reported may be due to the necessity for bilateral insular functions, such that damage in either hemisphere can result in AN symptoms. The main function of the insula is as an integrator of functioning of a large number of other brain regions, specifically balancing body homeostasis and adaptation to the environment. Its main function is as a connection system, and Nunn et al's hypothesis can be seen as a definition of AN as a sort of disconnection syndrome. The hypothesis that aspects of ED are related to interhemispheric integration has recently received indirect support from a study reported by Christman et al (61), who showed that both men and women with strong handedness preferences reveal higher degrees of body-image distortion and elevated scores on the Eating Disorders Inventory. This conclusion is based on the assumption that strong hand preference is related to lower degrees or efficiency of hemispheric integration. This hypothesis converges with the findings from our lab, indicating decreased interhemispheric communication in ED.
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The combination of variability in both intra – and inter- hemispheric connections may be a useful framework in which to think about the nosology of EDs as well. The movement of patients thorough the diagnostic categories of ED suggests an underlying systematicity, and it may very well be that finer definitions can be made when coherence and degree of connectivity among unilateral and bilateral brain regions are taken into account.
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[35] Workman L, Chilvers L, Yeomans H, Taylor S. Development of cerebral lateralisation for recognition of emotions in chimeric faces in children aged 5 to 11. Laterality Asymmetries Body Brain Cognit 2006;1(6):493-507. [36] Lieberman L. Social cognitive neuroscience: A review of core processes. Ann Rev Psychol 2007;58:259–89. [37] Vuilleumier P, Pourtois G. Distributed and interactive brain mechanisms during emotion face perception: Evidence from functional neuroimaging. Neuropsychol 2007;45(1):174-94. [38] Bibby H, McDonald S. Theory of mind after traumatic brain injury. Neuropsychol 2005;43(1):99-114. [39] Gillberg C, Gillberg CRM, Johansson M. The cognitive profile of anorexia nervosa: A comparative study including a community-based sample. Comprehen Psychiatry 1998;37(1):23-30. [40] Tchanturia K, Happé F, Godley J, Treasure J, Bara-Carril N, Schmidt U. 'Theory of mind' in anorexia nervosa. Eur Eat Disord Rev 2004;12(6):361-6. [41] Andreason PJ, Altemus M, Zametkin AJ, King AC, et al Regional cerebral glucose metabolism in bulimia nervosa. Am J Psychiatry 1992;149(11):1506-13. [42] Saxena S, Brody AL, Maidment KM, Dunkin JJ, Colgan M, Alborzian S, et al. Localized orbitofrontal and subcortical metabolic changes and predictors of response to paroxetine treatment in obsessive-compulsive disorder. Neuropsychopharmacol 1999; 21(6):683-93. [43] Denys D, Zohar J, Westenberg HGM. The role of dopamine in obsessive-compulsive disorder: Preclinical and clinical evidence. J Clin Psychiatry 2004;65S:11-7. [44] Tot S, Özge A, Çömelekoglu Ü, Yazici K, Bal N. Association of QEEG findings with clinical characteristics of OCD: Evidence of left frontotemporal dysfunction. Can J Psychiatry 2002;47(6):538-45. [45] Bruder GE, Stewart JW, Tenke CE, McGrath PJ, Leite P, Bhattacharya N, Quitkin FM. Electroencephalographic and perceptual asymmetry differences between responders and nonresponders to an SSRI antidepressant. Biol Psychiatry 2001; 49(5):416-25. [46] Gotlib IH, Ranganath C, Rosenfeld JP. Frontal EEG alpha asymmetry, depression, and cognitive functioning. Cognit Emotion 1998;12(3):449-78. [47] Silva JR, Pizzagalli DA, Larson CL, Jackson DC, Davidson RJ. Frontal brain asymmetry in restrained eaters. J Abn Psychol 2002; 111(4):676-81. [48] Larsen JK, Brand N, Bermond B, Hijman R. Cognitive and emotional characteristics of alexithymia: A review of neurobiological studies. J Psychosom Res 2003;54(6):533-41. [49] Taylor GJ, Parker JDA, Bagby RM, Bourke MP. Relationships between alexithymia and psychological characteristics associated with eating disorders. J Psychosom Res 1996;41(6):561-8. [50] Zonnevijlle-Bendek MJS, van Goozen SHM, Cohen-Kettenis PT, van Elburg A, van Engeland H. Do adolescent anorexia nervosa patients have deficits in emotional functioning? Eur Child Adolesc Psychiatry 2002;11(1):38-42. [51] de Groot JM, Rodin G, Olmsted MP. Alexithymia, depression, and treatment outcome in bulimia nervosa. Comprehen Psychiatry 1995; 36(1):53-60. [52] Corcos M, Guilbaud O, Speranza M, Paterniti S, Loas G, Stephan P, Jeammet P. Alexithymia and depression in eating disorders. Psychiatr Res 2000;93(3):263-6. [53] Rothschild L, Eviatar Z, Shamaia A. Social cognition: Encoding and representational processes among binging/purging spectrum patients compared with control group. Submitted. [54] Abbat-Daga G, Piero A, Gramaglia C, Fassino S. Factors related to severity of vomiting behaviors in bulimia nervosa. Psychiatr Res 2005;134:75–84.
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[55] Abbat-Daga G, Piero A, Rigardetto M, Gandione Gramaglia C, Fassino S. Clinical, psychological and personality features related to age of onset of anorexia nervosa. Psychopathol 2007;40:261-8. [56] Frassinetti F, Maini M, Romualdi S, Galante E, Avanzi S. Is it mine? Hemispheric asymmetries in corporeal self-recognition. J Cognit Neuroscience 2008;20(8):1507-16. [57] Kaplan JT, Aziz-Zadeh L, Uddin LQ, Iacononi M. The self across the senses: an fMRI study of self-face and self-voice recognition. Soc Cognit Affect Neuroscience 2008;3(3):218-23. [58] Keenan JP, Wheeler M, Platek SM, Lardi G, Lassonde M. Self-face processing in a callosotomy patient. Eur J Neuroscience 2003;18:2391-5. [59] Koshino H, Kana RK, Keller TA, Cjerkassky VL, Minshew NJ, Just MA. fMRI investigation of working memory for faces in autism: Visual coding and underconnectivity with frontal areas. Cerebral Cortex 2008;18:289-300. [60] Nunn K, Frampton I, Gordon I, Lask B. The fault is not in her parents but in her insula: A neurobiological hypothesis of anorexia nervosa. Eur Eat Disord Rev 2008;16(5):355-60. [61] Christman SD, Bentle M, Niebauer CL. Handedness differences in body image distortion and eating disorder symptomatology. Int J Eat Disord 2007;40(3):247-56.
Understanding Eating Disorders: Integrating Culture, Psychology and Biology, edited by Yael Latzer, Nova Science Publishers, Incorporated, 2011.
In: Understanding Eating Disorders Editors: Yael Latzer, Joav Merrick, Daniel Stein
ISBN 978-1-61728-298-0 © 2011 Nova Science Publishers, Inc.
Chapter 12
Self Psychology in the Treatment of Anorexia Nervosa and Bulimia Nervosa Eytan Bachar14, PhD and Yekutiel Samet, MA
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Department of Psychology, Hebrew University, Jerusalem, Israel and Department of Psychiatry, Hadassah University Medical Center, Jerusalem, Israel The theoretical conceptualization of self-psychology and the implications for the therapist’s stance, open up new opportunities for the treatment of anorexia nervosa (AN) and bulimia nervosa (BN). The major contributions of self-psychology to the treatment of these disorders are centered upon the following principles: 1) the conceptualization of food, its consumption and avoidance as fulfilling selfobject needs, 2) the unique therapeutic stance of the therapist as selfobject who tries to empathize with the patient from an experience-near position, and 3) the respect that the theory attributes to the significance of the symptoms for the patient. This chapter presents clinical vignettes which can exemplify some of the principles which underlie the self-psychological understanding of eating disorders and their cure. The chapter also reviews empirical studies that demonstrate: 1) The difficulties of mothers of AN patients in serving selfobject needs of their daughters, and the readiness of AN patients, more than normal controls, to serve selfobject needs of others, 2) Prediction of later development of an eating disorder based on personality features depicted by the theory and 3) The efficacy of self-psychological treatment in eating disorders.
Introduction As early as 1694 (1), a report on a disease with a description of anorexia nervosa, appeared in the medical literature. Until the beginning of the third decade of the 20th century, there were another seven reports of this disorder. In these reports, the authors hypothesized that the 14 Correspondence: Eytan Bachar, PhD, Department of Psychiatry, Hadassah University Medical Center, POB 12000, Jerusalem, Israel. E-mail: [email protected].
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disease had an organic origin and they offered as cure, several baths of salts and minerals. Since the 1930s recognition for a psychic origin has gained the upper hand and psychotherapy has become the major tool for treatment. Psychoanalysis, which undoubtedly plays a central role in the domain of psychotherapy, developed three models to conceptualize the understanding of pathology and cure in a person’s psyche. As in all other domains in science, so in psychoanalysis the emerging model contains the model, which preceded it. The first model is the drive-defense model. The development axis, according to this model, is the psychosexual one. The second model is embedded in the object-relations theory. In the development axis of this model, the individual proceeds along stages of separationindividuation. The third model, self-psychology, deals with a development along the narcissistic axis. One of Kohut’s (2) major contributions in his conceptualization of this developmental axis is that narcissistic reliance on others is not a developmental stage that has to be abandoned through maturational development as it is perceived in the object relations model. Kohut’s theory legitimizes this need of the individual to rely narcissistically on the other throughout his entire life. This kind of narcissistic reliance was termed by Kohut "relying on selfobject". In that kind of reliance, the figure on whom the person is relying upon, is ready to give up his/her needs and viewpoint and is ready to act within the perspective of the person relying on him. The healthy development on the narcissistic axis, according to Kohut, is from a total desperate and archaic reliance on selfobject, into a flexible and mature reliance. When the child is reared in an environment which permits reliance on significant others in an optimal narcissistic reliance, then he or she will be able to develop a strong and healthy sense of self and will be able to operate from within themselves the calming and regulating functions previously operated by the selfobject. The optimal reliance is enabled by an environment which is emphatic enough and presents in optimal dosage inevitable frustrations in empathy. An adolescent girl who develops an eating disorder does not believe that she can rely on human beings for the fulfillment of these selfobject needs. During the rearing process of these girls, a reversal of roles between the daughter and her parents may take place. The parent relies in a narcissistic manner on the child, i.e., expects that the child will not behave as one who has interests and viewpoints of his/her own, but will be attentive and fulfill the parent’s needs in calming, soothing and alleviation of painful affects. Under such circumstances the child might feel that he does not have the right to live his own life. Children who devote themselves to their parent’s well-being while ignoring their own internal needs and believing that human beings will not be able to fulfill for them their selfobject needs, are prone, according to self-psychology, to develop eating disorders (EDs) (3,4). The fragility of the anorexia nervosa (AN) or bulimia nervosa (BN) patient and her tendency to ignore her own needs, feelings, and interests, necessitate the application of a psychotherapeutic approach that will not impose an interpretation "from without", but rather experience-near "from within" attunement to the patient. Self-psychologically informed therapists, more often than traditional therapists, slip from free-floating attention to the patient into special attention towards vicarious introspection into the patient's sense of self. Special attention is given to the patients’ experience of the therapist's impact on their sense of self (5). According to Wolf (6), the patient in therapy with a self-psychologically oriented therapist feels that the therapist maintains an attuned stance rather than an adversarial one. The patient experiences the therapist's neutrality as benign, that is, the therapist is affectively
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on the side of the patient's self without necessarily joining the patient in all of his/her judgments. The therapist, according to Kohut (7), sees him/herself as being simultaneously merged with, and separated from, the patient. The stance of the self-psychologist is sometimes mistakenly thought to be supportive or sympathetic, as if the therapist were supposed to be kind and gratifying, to substitute in the here-and-now situation for the deprivation that the patient had suffered in early development. Self- psychology does not assert that by providing corrective emotional experience in the here-and-now, early deficits can be repaired or filled in. The activity of the therapist that enables the mutative process of the restoration of the self involves the awareness of the therapist of failures in being empathic to the patient's needs. Provided the therapist succeeds in establishing an empathic milieu, these failures will not be harmful. The therapist's ability to analyze them in the transference is what brings about the transmuting internalization, the taking over by the patient of functions of the self fulfilled by the therapist. In infancy and childhood, children do need to be mirrored, to be looked upon with joy and basic approval by delighted parental selfobjects. The role of the therapist is to create the proper ambiance for the mobilization of the patient's demands for mirroring and the free expression of these demands during the therapy session. The self-psychologically informed therapist meets these needs by acknowledging and attempting to understand the patient's feelings, wishes, thoughts, and behaviors from the patient's perspective (vicarious introspection-empathy) before proceeding into the interpretive work. The therapist does not actively soothe or mirror. He/she understands, acknowledges, justifies, and interprets the patient's yearning for soothing and confirming responses. The therapist does not actively admire or approve of the patient's grandiose experiences, but, knowing their crucial role in normal development, explains to the patient their role in the psychic equilibrium. Kohut (8) divides the psychotherapeutic work into two phases: the empathic mirroring phase (understanding), and the interpretation phase (explaining). He suggests that for patients with severe disturbances of the self, the whole therapeutic work will be done in the first phase. For ED patients, staying in this first phase of empathic mirroring is of crucial significance. These patients have been rarely understood and accepted for what they are (9). Interpretation for these patients can be experienced, especially at the beginning of therapy, as imposing onto them something from without (10). The unique therapeutic stance of selfobject bears great significance for this crucial therapeutic issue of interpretation being experienced from without or within (11). The self is the center of the individual's psychological universe. It is what we refer to when we say, "I feel" such and such; "I do" such and such. The healthy human self is experienced as a sense of wholeness, aliveness, and vigor, as an independent center of initiative over time and through space. This is the essence of one's psychological being (12). As explained above, when individual A refers to individual B and needs and expects B to fulfill for A an internal need that A cannot fulfill for him/herself, we can, in the language of self psychology, say that A refers to B as a selfobject. Individual A on that occasion expects individual B to behave as if B were not an independent center of initiative. In other words, the term "selfobject" refers to that dimension of our experience of another person that relates to that person's function of shoring up our self. The internal needs of the self that we have been referring to are needs for self-esteem, regulation of emotions, calming, soothing, and a feeling of continuity over time and space. The healthy self can, to a great extent, internally regulate self-esteem and can calm and soothe
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itself. A healthy self maintains a sense of consistency, cohesiveness and clarity of patterns of experiences and behaviors even if faced with considerable stress. In the course of such healthy functioning of the self, others may serve as selfobjects, but often temporarily in a mature and limited manner. Self-psychology (2) stresses that even healthy and mature individuals do require that their internal self needs will be met, at least partially, by selfobjects. However, their reliance upon such selfobjects is flexible and mature, i.e., they can endure and even outgrow failures of such selfobjects. The unhealthy self, on the other hand, is dependent, to a great extent, sometimes desperately and totally or archaically, on selfobjects to do what the underdeveloped self cannot do. The emergence of the self in childhood depends upon appropriate selfobject experiences. The therapist, in treating patients' disorders of the self according to self psychology, renews the growth of the self by serving as a selfobject to the patient. He/she emphasizes more and stays longer in the first stage of therapy, the phase of empathic understanding, than traditional therapists (2), before proceeding onto the explaining phase (the phase of interpretation). The therapist acknowledging the patient from the patient's unique perspective and interpreting "from within" rather than "from without" (11), evokes in the patient selfobject experiences and renews the growth of the self. An essential element in this process is the therapist's awareness of potential retraumatization in the transference caused by the therapist's empathy failures. The therapist conveys to the patient his/her special awareness of his own repeated potential failures by interpreting them to the patient.
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Self-psychology and eating disorders Barth (9) proposes that ED patients lack much of the feeling of being understood, of experiencing others making an active effort to understand their perspective. She vividly describes therapeutic sessions in which ED patients often feel criticized and diminished whenever the perspective of the therapist is felt to be different from their own. As therapy progresses, patient and therapist learn to identify where the therapist deviates from the patient's perspective. Patients in advanced stages of therapy can talk about their hurt feelings rather than trying to restore a sense of cohesion through bingeing and vomiting. Self psychology views EDs as disorders of the self. The core of this conceptualization of the disorder and its cure is that AN and BN patients cannot rely on human beings to fulfill their selfobject needs. Rather, they resort to food to fulfill these needs (9,13,14) Kohut (2) initially described two main selfobject needs: a) mirroring selfobject needs and b) idealizing selfobject needs. The AN patient derives her satisfaction for selfobject needs through food, mainly through mirroring selfobject experiences. Her need for grandiosity is met not by admiration or approval from her fellow human beings, but rather from her own notion that she possesses supernatural powers which enable her to avoid food. Everyone who meets AN patients becomes acquainted with their feeling of great triumph that comes with every pound they lose. The elimination or the ignoring of this substance, "food," fulfills mirroring selfobject needs. The BN patient derives satisfaction of her selfobject needs through food, mainly through idealizing selfobject experiences (9,14). Food is experienced by her as an omnipotent power: It supplies calmness and comfort and regulates painful emotions, including anger, depression,
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shame and guilt (9,14-16). Since food and the ceremonies around it are experienced as the main source for fulfilling selfobject needs, it is defended by her with much the same intensity that other people will adhere to a human selfobject. Goodsitt (4) identified in the AN patient an extreme manifestation of her inability to refer to human beings in order to fulfill her selfobject needs. She wishes to behave as if she were a selfless human being. In order to insure her selflessness, she sticks to the position of fulfilling selfobject needs for others, primarily her parents. Clinging to this position serves as a barrier that keeps others from being a selfobject for her. Her selflessness is expressed by her ignoring even her basic needs, such as nutrition and occupying space in the world. The typical observations of many parents of AN patients are: "She was our best child. She was obedient and never thought of herself and was always conscientious and aware of the needs of other family members." These observations ensue from the basic position of the AN girl as a selfless human being who devotes herself completely to the fulfillment of other's selfobject needs. A short footnote of Kohut (2) is of special interest to this feature of the AN patient who feels and behaves as a selfless human being. Kohut writes about the AN individual, who like any human being should invest in herself in order to live, but actually puts her life in danger since she can not perceive herself as someone who is worth the investment. The AN patient's great feeling of triumph upon losing more and more weight actually signifies that she is looking for ways to gratify her grandiose needs, and, hence, nourish herself, rather than actively wishing not to exist. However, the content that stands behind this triumphant feeling is again towards selflessness. This is because she says in effect, "I can be admired only by my success in relinquishing myself." Andre Green (17), who does not use the theoretical tools of self-psychology, provides further support to this view by proposing that the AN patient is characterized by what he terms "negative narcissism" or "death narcissism". By reducing her being she gains in his opinion, a sense of "immortality" via freeing herself from her body and bodily needs. A sense of omnipotence is thus obtained. Self psychology (13,14) assumes that EDs, like other disturbances of the self, originate from chronic disturbances in empathy emanating from the caretakers of the growing child. The uniqueness of EDs is that at some crucial point in her development, the ED child whose crucial narcissistic needs have not been met empathically, invents a new restorative system in which disordered eating patterns are used instead of human beings in order to meet selfobject needs. The child relies on this system because previous attempts to gain selfobject-sustaining responses from caregivers have been disappointing and frustrating. Support to the self-psychological notion that ED patients can not believe that other human beings are ready to fulfill their selfobject needs, and that others can be relayed upon, can be found in Lawrence's (18) observations, stemming from Kleinian rather than the selfpsychological approaches. According to Lawrence, the AN patient has psychically given up the idea of relationships, seemingly relinquishing any sense of relatedness to an object. Geist (13) maintains that the underdevelopment of the self is expressed as a central malignant feeling of emptiness. As a defense against this emptiness, the ED patient organizes through her symptoms some sense of control over the fear of emptiness. She controls the feeling of emptiness by ruthless, compulsive eating, or by creating a "controlled emptiness" by vomiting/laxative use, or avoiding food. In Geist's opinion, (13) eating is the most closely related activity to filling up or emptying. Food can become, therefore, a reliable selfobject for
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the ED patient in dealing symbolically with this feeling of emptiness. Over this selfobject she has complete control. Sands (14) adds another element to explain why food and eating behavior can serve as an attractive substitute for a human selfobject. In this respect, food is considered the first medium through which soothing and comforting experiences are transferred from parental figures. Ulman and Paul (19) suggest that as the BN patient feels that she does not deserve any "indulgence," her vomiting is an attempt to magically undo the disallowed overindulgence likely experienced during a binge. Additionally, disturbed eating behavior affords the AN and BN patient some kind of autonomy over reliance on human selfobjects, by providing a defense against total fragmentation and disintegration. But as Levin (20) suggests in his selfpsychological treatment of alcohol users, the substance cannot fulfill adequately the missing functions of the self. Substance that is taken-in must, of course, go out, highlighting that stable regulators can be built up only through transmuting internalization of human selfselfobject relationships. The aim of therapy is to reestablish in the ED patient confidence in the capacity of close human relationships to calm and mitigate dysphoric moods. For the therapist, such an endeavor requires a special patience and effort, and is very time consuming. The basic selfpsychological assumption is that if the therapist does provide an empathic environment and analyzes the patient's fear of retraumatization in her relationship with the therapist, the archaic narcissistic needs will be mobilized into the transference (14). However, in ED patients this development is slow (15), because the archaic narcissistic needs have been detoured into the disturbed eating behavior and are not readily available to fuel selfobject transferences.
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Empirical support for self-psychology Empirical support to the role of selflessness and being self-object to others as potentially predisposing the individual to develop ED, can be found in the studies of our group (21,22). In 2002 (21) we developed the "Selflessness Questionnaire", which quantifies the tendency to ignore one's own needs and serve the needs of others. This questionnaire has been found to distinguish successfully between ED patients and controls. In 2008 (22) we conducted a longitudinal study, showing that this feature of selflessness and being self-object for others (as quantified in the "Selflessness Questionnaire") can predict the development of ED and EDNOS in schoolgirls aged 12.5-16.5 years. Follow-up of these students for a period between 2-4 years revealed that high selflessness predicted the development of an ED with a sensitivity of 82% and a specificity of 63%. Low selflessness (i.e. when the girls have not sacrificed their own needs for the sake of fulfilling others'), has functioned as a protective factor against developing an ED even when holding dangerous environmental attitudes towards abnormal eating. In another study (23) we found empirical support for the deficiencies of mothers of AN patients in serving as selfobjects to their daughters. We compared in that study triads of AN girls and controls, their mothers and their fathers. The mothers of AN patients were found to show significantly lower levels of selflessness compared to control mothers. In keeping with
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previous studies (21), AN girls showed significantly higher levels of selflessness, i.e., invested significantly less in themselves and significantly more in significant others, than control objects. AN girls were sensitive to their mothers' signs of mental distress and showed heightened selflessness when their mothers exhibited depressive tendencies. Fathers of AN girls, in contrast to the mothers, did not lag behind control fathers in their readiness to behave as selfobjects for others. Similarly, the AN girls, in contrast to their attitude towards their mothers were not supersensitive to their fathers’ mood fluctuations. These findings may point at fathers as potential positive agents in the treatment of their daughters, not only with respect to the conflicts arising between daughters and mothers. The efficacy of the self-psychological treatment of EDs was investigated in a randomized, controlled study of 33 patients, comparing it with a specific kind of cognitive [Cognitive Orientation (CO)] therapy (24). Self psychology achieved significantly better results, in comparison to the CO therapy, both in removing overt symptomatology and with respect to the intrapsychic dimension of self cohesion.
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Eating disorders and borderline personality disorder Geist (13) paid attention to the difference between borderline personality disorder and EDs with regard to the issue of object relations. Whereas the borderline patient can swing between feelings of anger, fantasizing about destroying the object, and great attraction towards and wishing to unite with it, the ED patient gives up the option of relating to human objects as a source of comfort. Kohut's (8) distinction between symbiosis and selfobject ties may be potentially helpful in clarifying this difference. In symbiosis, the two partners reinforce one another. In self-selfobject ties, only one partner derives satisfaction of the selfobject needs. According to self- psychology conceptualizations, the parents of the ED patient have failed to satisfy the selfobject needs of their child, using, instead, the child to supply their own selfobject needs. As a consequence, the ED patient does not expect anymore human beings to fulfill her selfobject needs. Conversely, because future borderline patients are assumed to have been involved during childhood in an intense symbiotic relationship with their mothers (25,26), they maintain a deep involvement in human relationships, albeit unhealthy ones, with great swings between approaching and distancing. The following clinical vignettes illustrate the issues aroused by self psychology in the treatment of AN and BN patients.
Challenges for the therapist to feel empathy Many aspects of the behavior of AN and BN patients, primarily destructive aspects, are highly difficult to empathize with. How can a therapist empathize with the great triumph that the AN patient feels when she loses more and more weight? True, neither a therapist nor a normal parent should or could empathize with every feeling or behavior of his patient or child, but a basic empathic milieu should be established in order to enable growth. Basic understanding and acknowledging of the patient's perspectives should be given to allow such
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a process to occur, while at the same time one should refrain from identifying with these perspectives. One therapist on our staff, recognizing the need of an AN patient to satisfy her need for grandiosity, told the patient, "For you losing weight is a great achievement, and even a triumph. It is a pity that no one else in the world can admire you for that." In a subsequent session, the therapist succeeded in conveying a message of experience nearness (11) to the patient through mentioning the tension between his responsibility for her health and her own perspective. He succeeded in doing this by telling her the following metaphor: "You are like the pilot who suffers from vertigo, who plummets towards the sea convinced that he is rising towards the sky. All his senses tell the pilot that he is correct and one can easily understand him, but I am in the control tower, warning the pilot that he is falling." A bombastic manifestation of the patient's grandiose self during a session is another example of a taxing challenge for the therapist who wishes to acknowledge the patient's perspective.
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Vignette 1 F, a 28-year-old lawyer, free of BN symptoms in this phase of therapy, in a burst of grandiosity, demanded that the judge and opposing lawyer dismiss themselves from a case, because of their incompetence. She felt that they did not appreciate the merits and intellectual achievements that she had demonstrated during the trial in her logical arguments. The therapist knew that his patient's reaction of grandiosity was the result of a lack of confirmation and appreciation from her environment. He knew that to confront her with the harm that her grandiose self inflicts upon herself would not be curative. Yet, he felt that he could not empathize with her behavior on that occasion. The therapist attempted to solve this dilemma by referring to the tension between what he understood was the patient's need at that moment and his own perception of reality by saying, "I am sure that at this moment you would have liked me to be on your side, like the child who returns home beaten and dejected after fighting with the other children. He needs his mother to calm him and not to investigate what his part in the fighting was." While admitting the potential empathy failure, the therapist pointed out the discrepancy between F's need for total approval from him and then mentioned the elements of her behavior that were not to be investigated at that time. Perhaps curiosity was mobilized in the patient, because she said: "Specifically it is about my academic merits that I cannot stand criticism or even a lack of appreciation." The therapist confirmed this observation warmly, connecting it to the circumstances of her childhood that rendered this area of her life very vulnerable.
Experience-near stance versus experiencedistant stance It is essential for the self-psychological viewpoint that the therapist adheres to a "from within" experience-near stance that is experienced by the patient near to his/her subjective experience, rather than offering an experience-distant interpretation "from without." In the following
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vignettes, the therapists have found themselves giving interpretations that can be regarded as experience distant, interpretations "from without". (11)
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Vignette 2 The female therapist came from a Kleinian background and had recently gained acquaintance with self psychology. The improvement in L., her patient, subsequent to her shift in theory, was very substantial. L, a 27-year-old BN patient, was telling with great joy and enthusiasm of a new boyfriend, who, she had thought, was not previously interested in her, but was now calling and courting her. The therapist intervened and commented upon L's way of speaking: "You are talking quickly, like the way you eat. In both cases, you do this in order to cover up deeper feelings of sadness and anger." L abruptly stopped her cheerful story about the new boyfriend and a few minutes later burst into tears. Discussing this incident with the supervisor, the therapist explained that she had reached the conclusion about the patient's anger because she, herself, could not trace her own anger and wondered whether it came from the patient through projective identification, (a remnant of the therapist's previous Kleinian training). The supervisor commented, "This was an interpretation from without. It might be correct, but it is experience distant. It did not address the subjective experience of the patient and, therefore, it was not an experience-near intervention." After the supervisor had reviewed other cases in which this therapist failed to approach the inner feelings of the patient, the ability of this therapist to feel and acknowledge the inner experiences of her patients improved markedly. There was great improvement in L.'s symptomatology and in her ability to relate to other people. L ended therapy saying that the greatest improvement she felt was not only in the relief from her symptoms, but also in her new feeling of being able to initiate and trust her own judgment. This feeling of being an independent center of initiative heralds the emergence of a healthier self. In the next vignette, the therapist was acquainted with the self-psychological viewpoint, but failed to adhere to it.
Vignette 3 M, a 23-year-old woman diagnosed with AN, came to the session stating that the progress in her condition and in her life begun when she started to take notations about her thoughts, her therapy and especially, her dreams. "Therefore," she went on to claim, "I have to give credit for my improvement to my notes and not to the therapist." The female therapist interpreted that the patient was competitive and somewhat belligerent. The supervisor thought that this was an unfortunate example of a failure to empathically understand the patient from her subjective experience. The therapist, assuming an outside observer's perspective, interpreted completely "from without", from an experience-distant perspective. The content of the interpretation might have been correct, but what the patient needed, according to selfpsychology, specifically during the prolonged beginning stage of therapy, was to feel her therapist's efforts to empathically understand her "from within." M's newly developing
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capacity to search for her own existence and presence should have been approved of and acknowledged. She needed to feel successful, competent and skillful by contributing to her own improvement. The proper order for intervention in such a case, according to selfpsychology, would be to first make the patient feel that the therapist feels and acknowledges what she feels, namely discovering her competence and capacity to understand herself and contribute to her development. The interpretation about competitiveness, being more on the level of object relations than self-selfobject relations, should be postponed until the final stages of therapy or perhaps not be presented at all, depending on whether other material on the latter level was accumulating.
Self-object relationships During therapy, when patients come to realize that the mode of their existence in the world is as selfless human beings who are trying to fulfill others' selfobject needs, they are, on the whole, very much moved by this understanding However, their ability to integrate this realization into their current life is very slow and difficult, and does not always proceed simultaneously on the emotional and intellectual level.
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Vignette 4 A 23-year-old AN woman said, "I am accustomed to look for what fits others. If my boyfriend needs me to smile, I smile. I have become an expert in reading facial expressions. Depending on what my sister and my father need, I will be there to fulfill it. I can spend hours calculating if my brother needs to shower, and then wait for hours, not using the bathroom, because he might need it." This has initiated, during the next sessions, numerous vivid examples in which the patient has spontaneously remembered many times and places in which she has not felt comfortable with occupying space, for example while riding a bus. With the progression of therapy, she has gradually begun to feel more at ease to occupy space. For example, at dances and parties she can now enjoy herself and make her presence known. Another salient example to the sense of selflessness and existence just for the sake of fulfilling others' needs is exemplified in the next vignette.
Vignette 5 An AN patient recounted to her therapist the fact that while driving her car she could only sing if her young son was with her in the car. "As if singing is only for his sake and is only allowed in his presence, but alone, when I am by myself, never!". She said that she can not enjoy resting, sitting out in the sun, or watching TV. She feels she must work all the time or look out to be ready whether her husband needs her to do something for him. Despite her discomfort she always calls him 'Sir'. Only once a year in their joint vacation she allows herself to relax and rest.
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In one of the sessions she told her therapist: "I have no self-respect". When the therapist suggested that the way she handles her life indicates that she does not want to occupy space in the world, she said that she leaves early to work so that her car would not add to the traffic load. If someone is driving behind her she would move aside so that the other diver can pass, in order not to "get in the way". At her workplace she never told anyone of her Ph.D degree, and used to do the cleaning-up of the lab. When she said: "I always want to be small", the therapist elaborated by saying that she wants to be small both mentally and physically through her AN symptoms. The patients answered with: "I sit on floor pillows in order to be closer to the floor rather than on chairs like a human being". "When I make everyone at home coffee, naturally I serve them in fresh cups, but for myself I always use the same cup. It is already dirty and disgusting, but I nevertheless use it again and again." Upon asking for the reason for this she replies: "I don't know why I do this. I am humiliating and disgracing myself with this behavior, as if I do not deserve washing a cup for myself." The last vignette describes a young patient who has just started to develop egodystonic feelings towards her selflessness tendencies.
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Vignette 6 A 23-year-old BN patient, a year into therapy, is a good illustration of the ability of the patient to observe her first attempts to relinquish food while beginning to refer to human beings as potential providers of her selfobject needs. At the beginning of therapy, she expressed her attraction to food: "I like it so much that I have never found any love affair like it." She went on explaining why she prefers cake to a boyfriend. "With cake, you don't have to look at its face after you consume it desperately, but a boyfriend, if you want to lean on him, or be with him desperately, you will be embarrassed to look at his face afterwards." With progression of therapy, the patient felt great happiness whenever she chose human beings over food. She was astonished to realize that only the relationship with her boyfriend, his presence, the sight and smell of him and his touch, could overcome her attraction towards bingeing and purging. No other human being, neither her girlfriends nor her family, had a similar impact on her. "Had I been with him 24 hours a day, I would never binge." In the final stages of therapy, the patient could point out certain sessions and say, "That kind of feeling, being understood, can remove my intentions to binge and vomit."
Discussion Self psychology attributes a central therapeutic role to the therapist's effort to understand and acknowledge the patient's unique perspective. The patient's perplexing and even bizarre experiences are dealt with by the therapist's vicarious introspection, while approving the legitimacy of the patient's archaic needs. Such a therapeutic approach has great curative potentials for EDs in two major respects. First, it conveys to the ED patient the message that she deserves to enjoy the "services" of a human selfobject and that she deserves to be a self and not just a selfobject for others. Second, such a therapeutic stance of the therapist may
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restore in the patient the hope that human beings, rather than the substance, can provide her selfobject needs. Only through these self-selfobject relationships with human beings, in contrast with inanimate selfobjects like food, can the ED patient self-structure be repaired through the process of transmuting internalization, in which the therapist is aware of and acknowledges his failures of empathy. Hilda Bruch (10), whose pioneering insights into the treatment of EDs remain a landmark in the literature, intuitively felt that the two models of psychoanalytic development that existed in her time, the psychosexual and the object relations models, did not fit the therapy EDs. In attempting to summarize her life-long contribution to the field (10) Bruch remarks that the theory of self-psychology systematically conceptualizes the clinical phenomena and techniques to which she has intuitively pointed. Swift (27) suggested that Bruch's greatest contribution to the field is in the change that she promoted in the recommended stance of the therapist towards the ED patient. Long before the emergence of self-psychology, Bruch emphasized the necessary confirming of "the internal reality of the patients." (28,29). She opposed the therapist who gives interpretations from a "superior position" (Shall we say, in the language of self-psychology, "experience distant"?). She shunned an interpretive approach, being afraid that interpretation is often experienced by the AN patient as a recapitulation of early trauma in which the she was told what she thought and felt by a "superior other." Bruch also believed that interpretative interventions only confirmed the AN patient's sense of inadequacy’ likely interfering with her trust in her own self-expression (28,29) Swift (27) though, criticized Bruch for totally abandoning the important psychotherapeutic tool of interpretation. The suggested therapeutic stance of self-psychology can solve this dispute. Interpretations are given only a) after a long phase in which the patient feels that she is empathically understood and b) interpretations are given by a therapist who, the patient feels, is not a distant object, but rather a selfobject. Therefore, interpretations will be felt by the patient not as something imposed from without but as given from within. The self-psychological view of symptoms and defenses is another major element that renders self-psychology helpful in the treatment of EDs. The ED patient ferociously defends her eating pattern, like someone defending the existence of her own self. This is because she feels that if she gives up the eating ritual before genuine selfobject responsiveness can be substituted, she is seriously endangering her self-cohesion. Ornstein (30) stated that the selfpsychological approach to defenses and symptoms is very different from the confrontational approach adopted by classic psychoanalysis. Whereas, in the latter approach, according to Ornstein (30), defenses are viewed as obstacles that should be removed layer by layer, selfpsychology views them as performing the crucial psychological function of protecting a vulnerable self from further depletion or fragmentation. The ED patient treated according to the self-psychological approach will feel that even her self-defeating and self-destructive behavior patterns, which have been hitherto the target of condemnations and confrontations, are looked upon respectfully as attempts to restore and maintain a sense of cohesion, wholeness and vigor of the self. This is consistent with the message conveyed by the therapist to the patient, that her unique self deserves attention and her archaic needs warrant acknowledgment. Instead of being confronted with her behavior, the behavior is explained to her during treatment. The patient gradually learns that she cannot abandon her behavior until: she can rely on human beings to act as potential providers of her
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selfobject needs and her inner structures are established to take some of the roles of the external selfobjects. Sands (14) described a case in which the patient has been astonished by the understanding attitude of her self-psychologically informed therapist who had explained her disturbed eating patterns. The patient asks, "How can you say to a young girl that the Ipecac that she took to bring on vomiting was taken by her as an attempt to feel psychologically better?!" The therapist answers, "I'm trying to understand many aspects of your behavior, amongst these, the reasons for your bingeing and vomiting." Her previous therapist has viewed those ED behaviors as suicide attempts. While the destructive nature of those behaviors does not escape the therapist's attention, the self-psychological therapist does not overlook the curative attempts these behaviors try to fulfill. When the patient sees the genuine attempts of the therapist to understand her subjective viewpoint, suspending for a while the judgment of the faulty reality-testing elements of that behavior, she might take the next step of relating to the destructive nature of her behavior (7). This is likely illustrated by the patient's puzzled response to the therapist’s explanation of the Ipecac use. Idealization of the therapist is a frequently occurring emotion in patients. Idealization arises to some extent as a reaction to the great relief and gratitude towards someone who affirms and acknowledges the patient's subjective experience. Mostly it occurs, however, because of the developmental need to idealize a person who can supply a sense of calmness and with whom the patient can merge. More often than not, a therapist will find this idealization even more difficult to bear than devaluation. Self-psychology warns the therapist (31) against rejecting or interpreting this developmental need as a defense against other feelings, e.g., aggression or hatred, as Klein (32) might have interpreted. Sands (33) further suggests to check whether patient's devaluations of their therapists are manifestations of their defenses against long-term unmet needs for idealized selfobjects.
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Conclusions This chapter reviews the contributions of self psychology to the treatment and understanding of AN and BN. It attempts to show that the unique conceptualization of the self, selfobject relations, and the self-psychological conceptualization of resistance and defenses, constitute a therapeutic stance which specifically fits the therapeutic needs of ED patients. Clinical vignettes illuminate three main issues exemplifying the opportunities and dilemmas that this new development in psychoanalytic theory brings to the fore in the treatment of EDs: 1) empathy with deeds and attitudes of the patient that the therapist finds difficult to empathize with; 2) empathic understanding "from within", from an experience- near stance, vs. experience-distant interpretation "from without"; 3) self-selfobject relations with food, gradually transforming during therapy to self-selfobject relations human beings. We have presented in our chapter also empirical support for the efficacy of self psychology in the treatment of ED patients. We have also presented empirical evidence with respect to the lower capacity of mothers of AN patients, and the over-readiness of the AN daughter, to fulfill selfobject needs of others. Lastly, prospective longitudinal data have shown that the position of selflessness and being selfobject for others may predict the development of full-blown EDs and EDNOS.
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References [1] [2] [3] [4] [5] [6] [7] [8] [9] [10] [11] [12] [13]
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[14] [15] [16] [17] [18] [19] [20] [21] [22]
Morton R. Physiology of consumption. London: Smith Walford, 1694:5-6. Kohut H. The analysis of the self. New York: Int Univ, 1971 Goodsitt A. Eating disorders: A self-psychological perspective. In: Garner DM, Garfinkel PE. Handbook of psychotherapy for eating disorders. Second edition. New York: Guilford, 1997:208-28 Goodsitt A. Self psychology and the treatment of anorexia nervosa. In: Garner DM, Garfinkel PE. Handbook of psychotherapy for anorexia nervosa and bulimia. New York: Guilford, 1985:55-82 Berger D. Clinical empathy. Northvale, NJ: Jason Aronson, 1987 Wolf ES. Treating the self: Elements of clinical self-psychology. New York: Guilford, 1988 Kohut H. How does analysis cure? Chicago, Il.: Chicago Univ Press, 1984 Kohut, H. Building psychic structure that regulates self-esteem. In: Elson M.. The Kohut seminars. New York: WW Norton, 1987: 61-76. Barth D. When the patient abuses food. In: Jackson H. Using self psychology in psychotherapy. Northvale, NJ: Jason Aronson, 1991:152-9 Bruch H. Four decades of eating disorders. In: Garner DM, Garfinkel PE.. Handbook of psychotherapy for anorexia nervosa and bulimia. New York: Guilford, 1985 Schwaber E. A mode of analytic listening. In: Lichtenberg J, Bornstein M, Silver D. Empathy. New York: Analytic Press, 1984:143-72. Tolpin, M. Discussion of psychoanalytic developmental theories of the self: An integration by Morton Shane and Estelle Shane. In: Goldberg A. Advances in self psychology. New York: Int Univ Press, 1980:243-51. Geist R. A Self psychological reflection on the origins of eating disorders. J Am Acad Psychoanal 1989:17:5-28. . Sands SH. Bulimia, dissociation and empathy: A self psychological view. In: C. Johnson. Psychodynamic treatment of anorexia nervosa and bulimia. New York: Guildford, 1991:3450. Kohut H. Preface to psychodynamics of drug dependence. In: Blaine D, Julius DA. Psychodynamics of drug dependence. Washington, DC.: Gov Printing Office, 1977:3-10. Kohut H. The addictive need for an admiring other in regulation of self-esteem. In: Elson M. The Kohut seminars on self-psychology and psychotherapy with adolescents and young adults. New York: WW Norton, 1987:61-8. Green A. The dead mother. In Green A. Life narcissism death narcissism. London: Free Assoc Books, 2001:88-101. Lawrence, M. Loving them to death: The anorexic and her objects. Int J Psychoanal 2001;82:43-55. Ulman RB, Paul H. A self-psychological theory and approach to treating substance abuse disorders: The "intersubjective absorption" hypothesis. Prog Self Psychol 1989;5:121-41. Levin J. When the patient abuses alcohol. In: Jackson H. Using self psychology in psychotherapy. Northvale, NJ: Jason Aronson, 1991:203-21. Bachar E, Canetti L, Latzer Y, Gur E, Berry E, Bonne O. Rejection of life in anorexic and bulimic patients. Int J Eat Disord 2002;31:42-7. Bachar E., Gur E., Canetti L, Berry E., & Stein D. (2010). Selflessness and Perfectionism as Predictors of Pathological Eating Attitudes and Disorder: A Longitudinal Study. European Eating Disorders Review, 18(6): 496-506.
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[23] Bachar E, Kanyas K, Latzer Y, Canetti L, Bonne O, Lerer B. Depressive tendencies and lower levels of self-sacrifice in mothers, and selflessness in their anorexic daughters. Eur Eat Disord Rev 2008;6:184-90. [24] Bachar E, Latzer Y, Kreitler S, Berry E. Empirical comparison of two psychological therapies: self psychology and cognitive orientation in the treatment of anorexia and bulimia. J Psychother Pract Res 1999;8:115-28. [25] Mahler MS. The psychological birth of the human infant. New York: Basic Books, 1975. [26] Masterson JF. Psychotherapy of the borderline adult: A developmental approach. New York: Brunner Mazel, 1976. [27] Swift W. Bruch revisited: The role of interpretation of transference and resistance in the psychotherapy of eating disorders. In: Johnson C. Psychodynamic treatment of anorexia nervosa and bulimia.. New York: Guilford, 1991:51-66. [28] Bruch H. Psychotherapy in primary anorexia nervosa. J Nerv Ment Dis 1970;150:51-66. [29] Bruch H. Eating disorders: Obesity, anorexia nervosa and the person within. New York: Basic Books, 1973 [30] Ornstein A. Selfobject transferences and the process of working through. Prog Self Psychol 1990;6:41-58. [31] Kohut H. The psychoanalytic treatment of narcissistic personality disorders: Outline of a systematic approach. Psychoanal Stud Child 1968;23:86-113. [32] Klein M. Envy and gratitude. In: Klein M. Envy, gratitude and other works. London: Hogarth Press, 1957:176-236. [33] Sands SH. Eating disorders and female development: A self-psychological perspective. Prog Self Psychol 1989;5:75-103.
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In: Understanding Eating Disorders Editors: Yael Latzer, Joav Merrick, Daniel Stein
ISBN 978-1-61728-298-0 © 2011 Nova Science Publishers, Inc.
Chapter 13
Implicit Measures: Implicit Personality Characteristics and Implicit Processes in Eating Disorders
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Lily Rothschild-Yakar, PhD and Daniel Stein, MD The aim of this chapter is to gain a better understanding of the interrelations between personality dynamics and the development, maintenance, and response to treatment in eating disorders (EDs). For this purpose we review data derived from studies using implicit measures, e.g., the Rorschach and Thematic Apperception Test (TAT), or combine these tests with self-report measures. The Rorschach and TAT likely identify implicit experiences in personality dynamics (motives that influence an individual’s behavior automatically, often without any awareness), whereas self-reports are more likely to detect explicit phenomena (motives that a person acknowledges). Studies using implicit measures support the supposition that personality constructs related to reality testing, thinking disturbances, differentiation, autonomy, dependency, reflective functioning and metallization abilities differ between ED and non-ED individuals. Nonetheless, prospective longitudinal studies showing changes in implicit personality aspects, specifically in thinking disturbances, even after a relatively brief treatment period, may raise some reservations with respect to the stability of personality constructs diagnosed in the acute stages of the ED. The data summarized in this chapter suggests that the implementation of longitudinal studies utilizing both explicit and implicit measures may improve the differentiation between enduring personality traits potentially predisposing to an ED, state-dependent traits elevated only in acutely-ill patients, and traits considered a consequence of the illness. The contribution of combined explicit and implicit assessments to treatment planning lies in the ability of such paradigms to identify relevant underlying therapeutic focal points that would combine with the treatment of the overt ED symptomatology.
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Introduction In recent years there is a growing interest in the relationships between personalitycharacteristics and eating disorders (EDs) (1). Many studies have by now shown that underlying personality constructs may be of considerable importance in the predisposition to an ED, as well as in influencing the process and outcome of the disorder, including the response to treatment (1-3). Another topic of interest relates to the likelihood of different personality disorders and non-clinical personality traits in different ED subtypes. For example, individuals with anorexia nervosa, restricting type (AN-R) are more likely diagnosed with the DSM-IV (4) cluster C personality disorders and with non-clinical personality traits of inhibition, rigidity, and conformity (5,6). By contrast, individuals with bulimia nervosa (BN) are more likely diagnosed with the dysregulated DSM-IV cluster B spectrum of personality disorders primarily narcissistic and borderline personality disorders, although cluster C avoidant and dependent personality disorders are also elevated in these patients (1,2). Although BN patients share several non-clinical personality traits with AN-R patients, including perfectionism, harm avoidance and obsessioanlity, they are also characterized by other personality traits indicative of impulsivity, novelty seeking, reactivity to stress and affective dysregulation (1,2,7). The picture in the case of AN bingeing/purging type (AN-B/P) is less consistent. Individuals with this disorder may present with personality traits of both the “restrictive-inhibited” and the “dysregulated-impulsive” spectrum (2), or alternatively fare in-between the two spectrums in other personality categories (8), but most often, they are more akin to the B/P than the restrictive personality configuration (1,2,9). Studies of personality patterns and personality assessment in EDs need to address several important methodological issues. Firstly, a considerable controversy exists regarding the validity and clinical relevance of personality differences in different ED subtypes, as many patients (up to 60% in some recent studies) may shift among the restrictive, purging, bingeing, and bingeing/purging ED subtypes during the course of their illness (10). Another major drawback for evaluations of personality traits performed during the active phase of the illness, is that these evaluations may at least in part be influenced by the effects of the patients’ erratic comsummatory patterns (1,2). Thus for example, prolonged malnutrition may generate a clinical picture of anxiety, depression, obsessionality, concreteness, and social isolation (1,2,6). Stabilization of the physical condition and the restrictive patterns may result in a reduction in these attributes (5). Similarly, the reduction in behavioral dysinhibition in BN patients following symptomatic improvement, suggests that the elevated impulsivity and affective dysregulation in the acute state may reflect in part, the influence of the erratic switches between restrictive (i.e., over-control), and binge eating (i.e., under-control) behaviors (1,6). Furthermore, certain personality traits may be reduced in ED patients of all subtypes following treatment, suggesting the change in these traits to be related not only to a change in the physical condition and dieting pattern, but also to be directly associated with the effect of therapy (8). Most of the research on personality characteristics, and psychological dynamics of ED patients is based on self-report measures, notwithstanding extensive data suggesting that ED patients primarily, but not only those diagnosed with AN-R, may misperceive their state due to denial, minimization, or deficient awareness (1). Only relatively few studies have used performance based measures assessing implicit personality phenomena and intrapsychic
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processes, for example the Rorschach and the Thematic Apperception Test (TAT), to investigate the role of underlying personality aspects in EDs. Implicit measures (previously termed as projective tests), provide several types of data, mainly structural and thematic data. For example in the Rorschach test, the structural data involve a perceptual process attuned to the stimulus properties of the inkblots (e.g. form and color), whereas the thematic data derive from an associative process in which characteristics not inherent in the blot may be attributed to them (e.g. human figures described as being happy or sad). The interpretation of the structural data is based on the assumptions that the manners in which people perceive the inkblots represent how they generally perceive objects and events in their lives (e.g. a person who gives responses which deviates from the stimulus properties of the blot is likely to misinterpret experiences and events). The conceptual basis for interpreting the thematic data is based on the assumption that they come from inside the person and provide clues to his/her underlying needs, attitudes, conflicts, and concerns (11). The Rorschach is considered the most common implicit performance based measure used in clinical settings when an understanding of implicit personality dynamics is required. Bornstein (12) presents the model of dissociative approaches to diagnostic testing, in utilizing both self-report measures and projective tests. According to Bornstein, self-reports are more likely to detect explicit phenomena (motives that a person acknowledges), whereas the Rorschach likely identifies implicit experiences in personality dynamics (motives that influence an individual’s behavior automatically, often without any awareness). Bornstein further postulates that the measurement of implicit experiences is expected to be less susceptible to self-presentation biases than self-attributed explicit measures. Implementing both types of measures has the potential to identify rich clinical and research information of both overt and covert realms. In the present chapter, Rorschach and TAT data will be presented, including several studies combining these tests with self-report measures, to gain a better understanding of the interrelations between personality dynamics and the development, maintenance, and response to treatment in EDs. Most of the studies reviewed have implemented theory-generated designs related to ego functioning (specifically, reality testing and thinking disturbances), object relation theory and mentalization perspectives.
Ego deficits in eating disorders Hilde Bruch (13) was likely the first to conceptualize EDs in terms of ego pathology and interpersonal disturbances. The deficiencies in ego function in Bruch’s model include perceptual and conceptual derangements evident in severe body image disturbances, inaccuracy in identifying bodily and emotional states and needs, deficiencies in interpersonal and social capacities, an all-pervasive sense of ineffectiveness, and lack of autonomy. Moreover, according to Bruch, and also later self-psychology theorists (14), ED patients tend to be more invested in external reality and significant others, at the cost of decreased contact with their inner reality and internal sensations. The Rorschach studies assessing ego functions discussed in this chapter have mostly used the empirically-based Rorschach Comprehensive System (CS) (15,16). The CS provides a variety of variables and summery scores, based on structural and thematic data, measuring a
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wide range of personality aspects such as the ability to modulate affects, thinking disturbances, reality testing, and self perception. The validity of the Rorschach CS has been discussed extensively. Several studies have pointed to the validity of the Rorschach test, being considered equal to well-accepted standardized self-report measures such as the MMPI (17). Many studies have consistently supported the validity of the Rorschach CS in the study of personality, being equal in this respect to well-accepted standardized self-report measures such as the MMPI (17). Several Rorschach studies have shown that despite the sensitivity of ED patients to external cues, all different ED subtypes may be prone to misperceptions of their external reality (indicated by the high prevalence of responses that are markedly deviated from the form qualities of the blot), and to thinking disturbances (e.g.: objects and ideas integrated in an unlikely or a bizarre manner) in comparison with normal controls. A thinking disturbance is revealed, for example, in a response presented by an ED adolescent in one of our studies: “two people are trying to merge and be one person because they don’t like themselves. Once they are merged to being one person, they are able to love themselves”. Smith and his colleagues examined adult (18) and adolescent (19) purging and nonpurging BN patients, with the Rorschach CS method, showing greater pathology in thinking disturbances and in reality testing in both groups of BN patients, compared to normal controls. No differences were found between the two BN subtypes in both studies. By contrast, Weisberg et al (20), comparing among depressed patients, BN patients and controls, found that depressed patients showed greater impairment in thinking disturbances and reality testing than both BN patients and normal controls. No differences were found in thinking disturbance between BN patients and controls, although the former were significantly more impaired in their reality testing. These findings have crucial implications with respect to the perception and interpretation of reality of ED patients. Faulty reality testing and disturbances in the ability to form reasonable conclusions about events may be a global cognitive deficiency among ED patients, undermining their ability to correctly interpret and perceive social reality, rather than being a specific deficit related to food, body size and weight. From a clinical perspective, the faulty reality testing and thinking disturbances of ED patients are different from those of schizophrenic patients, as ED patients are not overtly delusional. Nevertheless, studies comparing schizophrenic and AN patients, with both selfreport measures of personality (e.g., the MMPI) (21) and the Rorschach (22), have found no significant between-group differences, with the mean scores of both groups being in the pathological range. Whereas these findings show once again the pervasive disturbance in the ego functioning of ED patients, they should be nevertheless, interpreted with reservation. This is because the aforementioned studies were undertaken in acutely ill ED patients, likely being severely deranged both psychologically and physiologically. Rothschild, Lacoua and Stein (23), have recently examined ego functions in acutely-ill AN-R patients and B/P spectrum ED patients, and when achieving symptomatic stabilization following integrative treatment, using both self-report measures and the Rorschach CS. In this study, AN-R inpatients have presented with significantly higher level of ego functions according to the implicit measure (Rorschach CS) in comparison to the B/P spectrum inpatients, specifically in the domains of impulse control and thinking disturbances.
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Nonetheless, these between-group differences have been found only in the acute state of the illness but not in symptomatically stabilized patients. It may be, thus, inferred that the higher deficiency in ego functions among the B/P spectrum patients represents state-dependent “personality-like” artifacts, as suggested by Vitousek and Stumpf (24) rather than enduring maladaptive traits. Alternatively, B/P spectrum patients, being less rigid in nature than AN-R patients (6), may respond better to treatment interventions at the short run (1).
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Interpersonal aspects Several authors within the framework of object relations theory described EDs as representing identity-related crises in the context of the separation-individuation conflict transferred to the realms of food and the body (25). Others have ascribed the deficiencies in the development of differentiated representations of the self and others and in the development of autonomy during adolescence as potentially predisposing to EDs (26). Undifferentiated internal object representations may be associated with misperceptions of internal states and interfere with the handling of adolescent turmoil (27). Bruch (13) and self-psychology theorists (14), propose that in their struggle towards autonomy, AN-R patients may deny any needs of dependency, both for human objects and for food, likely regarding their active refraining from food as organizing their sense of self-worth. By contrast, BN patients often present with ambivalence towards dependency, and are involved in a constant "tug of war" between the two poles of the dependence-independence axis, expressed both in the context of interpersonal relations and in the realm of food (28,29). Several studies have examined the dependency-related hypotheses in EDs, using the Rorschach Oral Dependency Scale (ROD) (30). This scale assesses implicit interpersonal dependency needs, and is considered the most widely used implicit measure of dependency. The ROD contains percepts related to various aspects of dependency, including oral imagery related to food, food organs (e.g. mouth, stomach) and food providers (e.g. cook, waiter). Bornstein and Greenberg (31), employing the ROD scale in EDs, have found that although ED patients produce as many food responses as normal-weight controls and obese individuals, they create significantly more oral imagery-related dependency responses (ROD) than these two other groups. This suggests that ED patients are preoccupied to a greater extent with their inclination to rely on others for nurturance and support than with their actual need of food. Fowler et al (28) also found elevated ROD scores in BN patients in comparison to normal controls, although the tendency of BN patients towards interpersonal dependency was lower in comparison to non-ED psychiatric patients. Furthermore, when using a different dependency scale (the Austen Riggs Hostile Dependency scale) measuring oral aggression in relation to food (e.g., spoiled food), human objects (e.g., cannibal) or animals (e.g. vampire), BN patients presented with more aggressive dependent responses than the psychiatric control group. The authors interpreted these data as implying that BN patients present with conflicting dependency/counter dependency yearnings towards human objects and food. Nurduzzi and Jackson (32) postulated that ED patients strive for autonomy to “defend” themselves against unconscious dependency needs. These authors assessed different ED subtypes (BN, AN-B/P, AN-R and ED-NOS) and a control group, using both self report
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measures of autonomy, and sociotropy/dependency and the Rorschach ROD scale.. Whereas no differences were found between the different ED subgroups in all measures, the ED patients as a group presented with significantly higher levels of explicit autonomy and explicit and implicit sociotropy/dependency compared with the controls. Accordingly, seemingly contradictory personality configurations might predispose to an ED, namely being overly invested in maintaining a sense of separateness from others and in achievement-related concerns while simultaneously being overly invested in maintaining dependent relations with significant others. The data that the self report sociotropy/dependency measure discriminate between the ED and control groups to a greater extent than the implicit ROD scale and also has a stronger association with B/P symptoms, suggest that ED women can acknowledge concerns related to dependency. This conscious (explicit) unconscious (implicit) dichotomy may argue against the conceptualization of BN as representing a defensive somatic maneuver escaping unconscious dependency/autonomy conflicts, as claimed by some object-relations researchers (33). Similarly, Bornstein (34) suggests the likelihood of bidirectional relations of the dependency-ED link. As dependency is related to a representation of the self as weak and inefficient, it might be either a risk factor or a result of the ED and/or of related psychopathology, specifically anxiety and depression. Deficiencies in the developmental processes of differentiation and individuation have been examined also with other Rorschach measures constructed in accordance with object relations models. Some of these scales are based on Mahler's developmental model (35), for example, the Mutuality of Autonomy Scale (MOA) (36). The MOA, which assesses the thematic content of interactions between people, animals, and inanimate figures, describes the self-other experience on a 7-point scale, along a continuum ranging between positive, empathic relatedness between two differentiated and autonomous subjects (e.g., “two woman holding together a basket”), to malevolent, engulfing, and destructive relations (e.g., “a fly being devoured by this monster”). The scores on the MOA combine to a mean score (MOAX) reflecting the level of maturity of personal differentiation and interpersonal relationships. A high degree of construct validity of the scale has been found in previous studies (36,37), showing an association between the level of maturity of the respective Rorschach representation and the extent of disturbance in personal and interpersonal functioning. Fowler et al (28) compared the mean MOA pathological score (PATH, a composite score of levels 5,6,7) of BN patients with that of normal controls and non-ED psychiatric patients. The representations of BN patients (MOAX) were similar to those of non-ED psychiatric patients and different from the controls, showing deficiencies in the ability to maintain an adequate sense of self and other as autonomous, and a cohesiveness of the body and the self. Furthermore, both clinical groups tended to experience interpersonal relations as malevolent. Parmer (29) found, according to another Rorschach developmental scale based on Mahler’s developmental model (the Scale of Separation-Individuation) (38), that BN patients showed significantly more responses indicating primitive levels of object relations compared to a control group. Specifically, BN patients gave more pre-separation phase (e.g. a boundaryless response: “a jellyfish… you can see through the blood vessels”), and early-differentiation phase responses of merging and hatching (e.g. “two girls with the same head”), indicating the likelihood of deficient self-other differentiation and of elevated preoccupation with separation- individuation themes. Based on this data, Parmer conceptualized the symptomatic switches in BN as representing a metaphorical enactment of the dependence-independence
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conflict, in which food and body are used as transitional objects to facilitate psychological differentiation. The few studies applying Rorschach measures to compare the level of differentiation and interpersonal relationships among different ED subtypes did not reach definite conclusions. For example, Piran (39), utilizing the Borderline Interpersonal Relations Scale of Kwawer (40) (focusing on primitive modes of object relations such as symbiotic merging), found that the percentage of protocols displaying primitive object relations themes was significantly higher among BN patients compared to AN-R patients. BN patients also exhibited more malevolent object representations than the restricting patients. By contrast, Hirshberg (41), utilizing the Symbiotic Phenomena Content Scale (SPCS) that was developed on the basis of Kwawer’ scale (40) and two other scales assessing primitive interpersonal modes in Rorschach content, did not find any difference between different ED subtypes (AN-R, ANB/P, and BN patients with or without a history of AN). Nonetheless, all ED subtypes presented with more primitive object relations in comparison to non-ED controls. Similarly, Strauss and Ryan (42), using the MOA scale, did not find any differences in the level of interpersonal relationships between AN-R and AN-B/P patients. Both subgroups exhibited less differentiated self-other representations and more malevolent relations, in comparison with a non-patient group. The inconclusive results with respect to the extent of deficiency in ego functions and object relations among different ED subtypes, led several authors (42), to suggest that EDs should be conceived as borderline phenomena, and that all ED subtypes are organized at the borderline level.
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Object relations, social cognition and mentalization Recent conceptualizations postulate that damage to the development of reflective functions and metallization abilities may predispose to deficiencies in the interpersonal realm (44), which might, in turn, increase the risk for the development of an ED in the context of other relevant vulnerabilities. The construct of Reflective Function refers to the capacity to reflect and interpret one’s behavior and the behavior of others in terms of intentional internal mental states such as thoughts, feelings, and beliefs. The damage to the development of mentalization may predispose to an ED at it likely interferes with the development of important capacities such as the capability for affect regulation, impulse control and the experience of self-agency (27). Westen (45) has developed The Social Cognition and Object Relation Scale (SCORS) to analyze the representations and working models revealed in TAT narratives. The scales in this tool integrate social-cognitive, cognitive-developmental, and psychoanalytic conceptualizations with respect to object relations and social cognition. The affective scales of the SCORS include the Affect-Tone of Relationship Scale (AT) and the Capacity for Emotional Investment Scale (CEI). The cognitive scales of the SCORS (the Complexity of Representation Scale (CR) and the Understanding of Social Causality (USC) Scale) measure the degree to which the individual clearly differentiates the perspectives of self and others and the ability to attribute logical, complex and psychologically-minded causes to interpersonal
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interactions. The developmental cognitive scales of the SCORS are conceptualized as measures of mentalization ability (46). Kernhof et al (46) used the SCORS to analyze TAT narratives of psychosomatic female patients with a history of sexual abuse, female ED patients with no history of sexual abuse, and non clinical female controls. The authors found that compared to the control group, ED patients had significantly lower scores on the affective scales (AT and the CEI) of the SCORS. Furthermore, both research groups presented with similar pathological levels on the CEI. These data point out that in comparison with the controls, the ED patients were inclined to perceive interpersonal interactions as malevolent and hurtful, to show difficulties with feeling empathy, and to be more self-focused. No differences were found in the cognitive scales between the ED patients and controls. The lack of empathy in the ED group was related to the likelihood of elevated narcissism in these patients, evident in a more defined self focus and a greater preoccupation with one’s own body and person. A somewhat different result was found in another study, using, among other measures, the cognitive scales of the SCORS (47), to assess the level of reflective function in AN B/P patients. AN-B/P patients scored significantly lower on these scales compared to a matched non-patient group, likely demonstrating a deficiency in the development of mentalization. Moreover, low mentalization was positively correlated with some core ED symptoms, including drive for thinness and lower body mass index (BMI), but not with the severity of B/P symptoms.
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Changes in personality attributes Empirical studies investigating changes in personality attributes during the course of an ED, whether in naturalistic or treatment-generated studies, have shown an improvement in some personality characteristic but not in others. This suggests that the former may in part represent state-dependent characteristics influenced to some extent by malnutrition and the patients’ erratic consummatory patterns, whereas the latter may represent premorbid, enduring personality configurations, potentially predisposing to an ED (1,24). To date, most studies assessing the stability/change in personality attributes in EDs over time use self-rating questionnaires, e.g., the DSM-IV structured clinical interview for personality disorders (48) or Cloningers’ Temperament and Character Inventory (8). Our group, on the other hand, in line with Bornstein’s (12) paradigm, has recently used a combination of explicit (self-rating scales assessing anxiety, depression, and core ED-related symptomatology and personality traits) and implicit (Rorschach CS) measures. These measures have been administered to acutely-ill newly admitted AN-R and B/P spectrum (ANB/P and BN) female adolescent inpatients, and again upon discharge when these patients have achieved symptomatic stabilization. The treatment protocol in this inpatient department is integrative and multimodal, including individual psychotherapy focusing on personality dynamics alongside other treatment modalities and nutritional rehabilitation. In our first study (49), in line with Blatt and Zuroff’s (33) defense hypothesis, we have proposed that EDs may develop to some extent as a defense against psychic pain. The results of this study show that for both the restricting and B/P subgroups, stabilization of weight and improvement of disordered eating have been accompanied by a reduction in explicit affective
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distress, and an increase in implicit affective distress. We suggest that if EDs are, to some extent, a defense against mental pain, then the stabilization of ED symptoms may reflect a reduction in the overt explicit manifestations of this pain (evidenced in our study in the reduction in self-rated depressive and anxiety symptoms). The improvement in overt symptomatology along with the effect of psychotherapy, likely promotes a reduction in the patients’ defensive avoidant need of control over their thinking and feeling. This, in turn, may render the patients to be more in touch with their underlying implicit body-mind difficulties (evidenced in our study in the increase in unconscious affective distress). From a different perspective, Rothschild et al (49) have found that AN-R patients present with an increase in the Rorschach CS measure of emotional responsiveness upon reaching symptomatic stabilization, whereas symptomatically improved B/P spectrum patients, tend to exhibit greater emotional avoidance. Thus, whereas symptomatically stabilized AN-R patients seem to be more in touch with underlying thoughts and feelings following treatment B/P spectrum patients are more defensive and in greater control as a mean to cope with the unfolding changes at that stage. Our studies have shown different baseline findings and different configurations of change following psychotherapy and symptom-related treatment between restricting and B/P patients also in relation to several personality domains. For example, Rothschild et al (23) have shown that on admission, B/P patients present with greater disturbance on the Rorschach CS markers of thinking disturbances and impulse dysregulation compared with the AN-R group. However, these between-group differences are no longer found in stabilized patients at discharge. This discrepancy suggests that the greater severity of thinking disturbances and affective dysregulation in acutely-ill B/P spectrum patients may result from the inherent fluctuations in these patients between over- and under-control (1,6). Taken together, our findings seem to contradict, in part, the paradigms of several important psychoanalytical (33), and cognitive behavioral (50) theorists, who have particularly emphasized the similarity in basic vulnerabilities in all ED types. We agree with those researchers claiming that although different types of EDs do share several underlying predisposing psychobiological derangements, other important disturbances may account for the differences in the symptomatic expression during the acute stage of the illness (2,6). Our findings add to this baseline differences suggesting that different change trends and personality dynamics may be revealed also during the course of the disease and in the response to treatment. Accordingly, psychotherapeutic interventions aimed towards deeprooted personality changes in ED patients, alongside symptomatic treatment geared towards physical and behavioral improvement, may have both similar, and different focuses in restricting vs. B/P patients.
Conclusions The data presented in this chapter showed that studies implementing implicit measures supports the supposition that personality constructs related to reality testing, thinking disturbances, differentiation, autonomy, dependency, reflective functioning and metallization abilities differ between ED patients and non-patients controls. Nonetheless, prospective longitudinal studies such as those conducted by Rothschild et al (23,49) showing changes in
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implicit personality aspects, specifically in thinking disturbances even after a relatively short treatment, may raise some reservations with respect to personality constructs diagnosed in the acute stages of the ED (1,2,24). Future prospective longitudinal studies utilizing both explicit and implicit measures, carried out in large outpatient samples from the onset of the ED to recovery, or lack of recovery, are needed to improve the differentiation between enduring personality traits potentially predisposing to an ED, state-dependent traits that are elevated in acutely-ill patients and may decrease thereafter, and traits considered a consequence of the illness. The addition of implicit assessments of underlying personality constructs to currently standardized interviews and self-report measures may be of particular relevance in defining long standing personality dynamics. The contribution of combined explicit and implicit assessments to treatment planning lies in the ability of such paradigms to identify relevant underlying therapeutic focal points that would combine with the treatment of the overt ED symptomatology. The last two decades have envisioned a considerable dispute with respect to the therapeutic paradigms considered valid, or invalid, in the treatment of EDs, between treatment approaches focusing on ED symptoms and overt cognitions (mainly CBT) versus psychotherapy focusing on personality dynamics combined with symptomatic treatment. Our findings highlight the importance of dialectics vs. dispute. This because the combination of explicit (“cognitive behavioral”) and implicit (“personality dynamics”) measures may provide a more comprehensive understanding of the role of personality–related issues in the genesis and maintenance of an ED, as well as in the response to treatment. These data point to the need to combine treatment strategies targeting changes in personality dynamics to other strategies aimed towards symptomatic improvement to better address the multitude of problems present in the treatment of ED patients.
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[31] Bornstein RF, Greenberg RP. Dependency and eating disorders in female psychiatric inpatients. J Nerv Ment Dis 1991;178:148-52. [32] Narduzzi KJ, Jackson T. Personality differences between eating-disordered women and a nonclinical Comparison sample: A discriminant classification analysis. J Clin Psychol 2000;56:699-710. [33] Blatt SJ, Zuroff DC. Interpersonal relatedness and self-definition: Two prototypes for depression. Clin Psychol Rev 1992;12:527-62. [34] Bornstein RF. A Meta-Analysis of the Dependency–Eating-Disorders Relationship: Strength, Specificity, and Temporal Stability. J Psychopathol Behav Assess 2001;23:15162. [35] Mahler M. Symbiosis and individuation. Psychoanal Study Child 1974;29:89-106. [36] Urist J. The Rorschach test and the assessment of object relations. J Pers Assess 1977;41:39. [37] Urist J, Shill M. (1982). Validity of the Rorschach Mutuality of Autonomy Scale. J Pers Assess 1982;46:450-4. [38] Coonerty S. An exploration of separation- individuation themes in the borderline personality disorder. J Pers Assess 1986;50:455-71. [39] Piran N. Borderline phenomena in anorexia nervosa and bulimia. In: P Lerner, H Lerner. Primitive mental states and the Rorschach. Toronto: Int Univ Press, 1988:363-76. [40] Kwawer J. Primitive interpersonal modes, borderline phenomena, and Rorschach content. In: J Kwawer, H Lerner, P Lerner, A Sugarman. Borderline phenomena and the Rorschach test New York: Int Univ Press, 1980:89-105. [41] Hirshberg LM. Rorschach images of symbiosis and separation in eating-disordered and in borderline and nonborderline subjects. Psychoanal Psychol 1989;6:475-93. [42] Strauss J, Ryan RM. Autonomy Disturbances in Subtypes of Anorexia Nervosa. J Abnorm Psychol 1987;96:254-8. [43] Lerner P. Psychoanalytic perspectives on the Rorschach. Hillsdale, NJ: Analytic Press, 1988. [44] Fonagy P, Leigh T, Steel M, Steel H, Kennedy R, Matton G, et al. The relation of attachment status, psychiatric classification and response to psychotherapy. J Counse Clin Psychol 1996;64:22-31. [45] Westen D.Current rating summary sheet. Atlanta, GA: Emory University, 2002. [46] Kernhof K, Kaufhold J, Grabhorn R. Object relations and interpersonal problems in sexually abused female patients: An empirical study with the SCORS and the IIP. J Pers Assess 2008;90:44–51. [47] Rothschild L, Levi-Shiff R, Balaban R, Gur E, Stein D. Mentalization and relationships with parents as predictors of Eating Disordered Behavior. J Nerv Ment Dis 2010:198: 501507. [48] Clausen L. Time to remission for eating disorder patients: a 2(1/2)-year follow-up study of outcome and predictors. Nord J Psychiatry 2008;62: 151-9 [49] Rothschild L, Lacoua L, Eshel Y, Stein D. Changes in defensiveness and in affective distress following inpatient treatment of eating disorders: Rorschach comprehensive system and self-report measures. J Pers Assess 2008;90:356-67. [50] Fairburn CG, Cooper Z, Shafran R. Cognitive behavior therapy for eating disorders: a “transdiagnostic” theory and treatment. Behav Res Ther 2003;41:509-28.
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In: Understanding Eating Disorders Editors: Yael Latzer, Joav Merrick, Daniel Stein
ISBN 978-1-61728-298-0 © 2011 Nova Science Publishers, Inc.
Chapter 14
Cognitive Orientation and Eating Disorders Shulamith Kreitler15, PhD
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Department of Psychology, Tel Aviv University, Tel Aviv and Psycho-oncology Research Center, Chaim Sheba Medical Center, Tel Hashomer, Israel The chapter presents the cognitive orientation (CO) approach to eating disorders (EDs). CO is a theory based on the assumption that behaviors and disorders are a function of a motivational disposition, determining the directionality of behavior, and a behavioral program, determining the manner of performance of the motivational disposition. The motivational disposition is defined by beliefs of four types – about the self, goals, norms and general beliefs – referring to specific themes, identified with a particular interviewing procedure, that represent meanings relevant for the particular disorder. Investigating the CO of an ED consists of identifying that particular set of beliefs that characterizes it, i.e., that enables the differentiation between individuals with and without the ED The chapter further describes the CO of the three major EDs. The CO of obesity includes 20 themes. Some themes orient towards overeating, either directly or through evocation of conflicts, whereas other themes are focused on attempts at reducing weight. The CO of anorexia nervosa (AN) includes 30 themes, manifesting primarily withdrawal from oneself and from life. The CO of bulimia nervosa (BN) includes 33 themes manifesting in addition to withdrawal from oneself and others also a striving towards normalcy. Comparing the CO sets of obesity, AN, and BN, reveals 10 themes shared by all disorders, suggested to form the “general EDs CO core”. Finally, the major components of a blueprint for a new ED-related CO-based theory and treatment intervention are described.
15
Correspondence: Professor Shulamith Kreitler, PhD, Department of Psychology, Tel-Aviv University, IL-69978 Tel Aviv, Israel. E-mail: [email protected].
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Introduction Eating disorders (EDs) are a group of disorders focused on eating as an act of behavior as well as a construct with emotional, motivational and cognitive connotations. This focus serves also as a starting point for the approach of cognitive orientation (CO) to EDs. CO is a theory designed to enable the understanding, prediction and change of behaviors. It includes five sets of CO models which refer to overt behaviors (e.g., reactions to failure), cognitive acts (e.g., memory), emotions (e.g., tendencies towards depression), psychopathology (e.g., schizophrenia) and physical health (e.g., cancer). All share a common core which includes a set of theoretical tenets with a model about the generation of behavior (see figure 1), a research methodology, and a structured intervention procedure. The first part of the chapter presents the general components of the CO approach. The second part focuses on EDs, describing the CO models of obesity, anorexia nervosa (AN), and bulimia nervosa (BN), including the components they share, and preliminary findings with regard to the effects of CO-related treatment interventions.
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Cognitive orientation theory The major theoretical assumption of the CO approach is that cognitive contents and processes play an active-dynamic role in regard to behaviors. Behavior is considered a function of a motivational disposition, which determines the directionality of behavior, and a performance program, which determines the manner in which the respective behavior is carried out. Contrary to other cognitive models of motivation (1,2) the CO theory does not assume that behavior is guided by rationality, realism, decision- making, and conscious voluntary control. Instead, it focuses on the major role of meanings, showing the manner in which behavior proceeds from meanings and clustered orientative beliefs, which may be neither rational nor logical (3). The CO theory provides detailed descriptions of the processes intervening between input and output (4). These can be grouped into four stages, each characterized by metaphorical questions and answers. The first stage is initiated by an external or internal input and is focused on the question “What is it?” It aims towards identifying the input by a limited ‘initial meaning’ as either a signal for a defensive, adaptive or conditioned response, a molar action, an orienting response, or as irrelevant. The second stage is initiated by the feedback that the input has not been disposed of or identified. Focusing on the question “What does it mean in general and what does it mean to or for me?” results in an enriched process of generating interpersonally-shared and personal meanings in terms of beliefs, designed to determine whether these beliefs require a behavioral action. A positive answer initiates the third stage focused on the question “What will I do?” The answer is sought by means of relevant beliefs of four types: a) Beliefs about goals, which express actions or states desired or undesired by the individual (e.g., ‘I want to be respected by others’); b) Beliefs about rules and norms, which express ethical, esthetic, social and other rules and standards (e.g., ‘One should be assertive’); c) Beliefs about the self, which express information about oneself, such as one’s habits, actions or feelings (e.g., ‘I often get angry’)
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and d) General beliefs, which express information about others and the environment (e.g., ‘The world is a dangerous place’). The beliefs refer to deep underlying meanings of the involved inputs rather than their obvious and explicit surface meanings. The meaning elaborations are based on clarifying the orientativeness of the beliefs (i.e., the extent to which they support the indicated action). If the majority of beliefs in at least three belief types support the action, a cluster of beliefs is formed (“CO cluster”), orienting toward a particular act. It generates a unified tendency (called a behavioral intent) which represents the motivational disposition orienting toward the performance of the action. If a behavioral intent has been formed, the fourth stage is focused on the question “How will I do it?” The answer is in the form of a behavioral program, namely, a hierarchically structured sequence of instructions specifying the strategy and tactics governing the performance of the act. There are four basic kinds of programs: a) Innately determined programs, e.g., controlling reflexes; b) Programs determined both innately and through learning, e.g., controlling instincts or language behavior; c) Programs acquired through learning, e.g., controlling culturally shaped behaviors and d) Programs constructed ad hoc, in line with relevant contextual requirements.
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Research on prediction of behavior A large body of research demonstrates the predictive power of the CO theory in regard to a great variety of behavioral domains and types of participants. Predicting behavior by means of the CO theory enables mostly correct identification of 70%-90% of the participants manifesting the behavior of interest (5-22). The success of the predictions is based on applying the special standardized procedure developed in the framework of the CO theory (10). The procedure consists of assessing the motivational disposition for the behavior (viz. behavioral intent) by means of a CO questionnaire, and of examining the availability of a behavioral program for implementing the intent. A CO questionnaire assesses the degree to which the participant agrees to relevant beliefs orienting toward the behavior in question. The relevant beliefs are characterized in terms of form and contents. In form, they refer to the four types of beliefs, namely, beliefs about goals, rules and norms, the self, and general beliefs relating to others and the reality. In contents, they refer to the meanings underlying the behavior in question (called “themes”). The themes of a particular CO questionnaire are identified by means of a standard procedure applied to pretest participants that manifest the behavior in question and to control subjects not manifesting it. The procedure consists of interviewing the participants about the meanings of relevant key terms followed by sequential (three times) interviewing about the personal-subjective meanings of the participants’ responses. Repeating the questions about the meanings reveals deeper-layer meanings; those meanings recurring in at least 50% of the interviewees with the disorder and in less than 10% of those without it are selected for the final questionnaire. Noteworthy, the beliefs in a CO questionnaire do not refer directly or indirectly to the behavior in question but only to the themes that represent the underlying meanings of this behavior. Thereafter, the CO questionnaire is tested in another sample of individuals with the disorder in question and controls. Validity is confirmed if the CO questionnaire enables the prediction of the disorder also in the second sample.
Understanding Eating Disorders: Integrating Culture, Psychology and Biology, edited by Yael Latzer, Nova Science Publishers, Incorporated, 2011.
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Figure 1. A Schematic Flow-Chart of the CO Model.
The themes and belief types define together a prediction matrix, whereby the beliefs form the columns and the themes, the rows. Thus, a CO questionnaire mirrors the prediction matrix. It usually consists of four parts presented together in random order. Each part represents one of the four belief types, and contains beliefs referring to different theme-contents. Participants are requested to check on a 4-point scale the degree to which each belief seems true (or correct) to them. The CO questionnaire provides scores for each belief type across the themes and for each theme across the belief types. The scoring is determined in line with the pretest findings, so
Understanding Eating Disorders: Integrating Culture, Psychology and Biology, edited by Yael Latzer, Nova Science Publishers, Incorporated, 2011.
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that the higher the score the stronger the support for the relevant behavior (or disorder). The availability of the behavioral program is established by means of questionnaires, observation, information from others and/or role-playing.
The cognitive orientation of eating disorders In terms of the CO approach, eating disorders (EDs) are the product of a motivational disposition consisting of the four belief types and relevant specific themes, implemented by a behavioral program. The investigation of the CO theory of an ED consists of identifying the particular set of beliefs that characterizes it, namely, enables the differentiation between individuals with the ED and healthy controls or individuals with other disorders.
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The cognitive orientation of obesity The CO Questionnaire of Obesity has been constructed on the basis of interviews with pretest participants and controls and includes beliefs referring to the following 20 themes: 1) Avoidance of limitations, duties, obligations and external pressures; 2) Avoidance of overt expressions of hostility and of harming others; 3) A chronic feeling of guilt coupled with the need to act differently than one does; 4) Vulnerability, expressed in terms of feeling in danger and needing protection when being outside and "exposed" to a world that is often threatening; 5) Avoidance and renunciation of self control, accompanied by submitting oneself to impulsive acts; 6) Avoidance of any pain, unpleasantness or deprivation, striving only for pleasure; 7) Avoidance of physical activity as it is regarded as egotistical, time-consuming and effortful; 8) Conformity, i.e., behaving in accordance to social requirements rather than to one's own wishes; 9) Awarding oneself rewards following "good" behavior and harsh punishments following "sinful" acts; 10) Unclear self-identity, coupled with emphasis on maintaining one’s identity; 11) Fear of death, accompanied by preoccupation with impending catastrophes, and with threats to the striving for life and to one’s sense of living; 12) External control, related to the belief about the impossibility of changing anything determined in the past by heredity, biological temperament or way of life; 13) Dissociation between the external and internal self, whereby the latter is conceived as something that should be hidden, differentiated from the external self and not manifested through it; 14) Addictions are ineradicable and cannot be treated, controlled, changed or conquered; 15) Striving for success and achievement coupled with a fear of failure; 16) Fantasy being more important than reality; 17) Avoidance of dependence on others in any form, including receiving help and advise from friends; 18) Sense of loneliness, abandonment, and getting no support from others; 19) Avoidance of expressing overt emotions with regard to other people, hiding what one feels and 20) Lack of clarity about one's psychological gender identity, confusion about one's femininity, sense of multiple gender manifestations with respect to oneself and others, emphasis on the need to efface gender distinctions. The CO questionnaire was administered to a group of 64 overweight women and 64 matched women with regular weight (8). The overweight women scored significantly higher than the controls in all four types of beliefs, and in 19 of the 20 themes, indicating that these
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underlying motivations are characteristic of obesity. The application of a stepwise discriminant analysis enabled the correct identification of obese vs. non-obese women on the basis of the CO scores alone in 88.3% of the cases (i.e., 33.3% improvement over the chance level of 50%, p