Eating Disorders (ED) is one of the most common psychiatric problems faced by females (Walters & Kendler, 1994), and there has been a significant increase in EDs overtime. There are different types of EDs including Anorexia Nervosa, Bulimia Nervosa, and Binge- Eating Disorder. This essay aims to explore the risk factors for developing these disorders and how they are applied to treatment and therapeutic interventions.
Anorexia Nervosa (AN) is a self- starvation disorder in which the person retains a strong need to be extremely thin and their motivation is provided by the fear of becoming obese. The major characteristics of AN include denial to maintain a minimal body weight, fear of gaining weight and a misrepresented body image (Davey, 2008). There are two types of AN: a restricted type, which comprises of people who do not engage in purging while self- starvation, and binge eating/ purging type who use purging to maintain their weight. Overweight people are more likely to be affected by this disorder (Stice & Presnell, 2010) Comparable to AN, Bulimia Nervosa (BN) is a fear of gaining weight with also a disturbed perception of body shape, but the person does not become underweight because of its purging. A significant feature of BN is repeated incidents of binge-eating, with an individual experiencing one to thirty episodes of binging per week (Fairburn et al., 2008). Because of binging the person uses compensatory behaviours, such as vomiting, to relieve the physical feeling of fullness and anxiety. Binge- eating disorder (BED), like BN, entails recurrent eating binges, however, unlike BN, there is no performance of compensatory behaviours. Most individuals suffering from BED tend to be overweight (Claudino & Morgan, 2012) which then causes them distress and anxiety.
The risk factors for developing an EDs tend to be multifactorial and diverse, there could be biological, psychological or sociocultural factors behind the cause of the disorder.
A dominant sociocultural factor is the influence of media; the Western standards of the ideal female body shape are thought to be rather responsible for the emergence of these disorders, as a strong preference for an overly thin body figure has emerged, this is known as the ‘thin- ideal internalization’. This is supported by research conducted on Miss America’s contestants, as a significant decline in the body mass index (BMI) of the current winners was found and they were put in the range of undernutrition (Rubinstein & Caballero, 2000). Media, parental or peer pressures could cause body dissatisfaction (BD) and therefore cause dieting. Both BD and dieting are found to be major predictors of EDs (Stice, Shaw & Nemeroff, 1998). Peer pressure can influence eating behaviour, research has found that perceived pressure to be thin from peers relate to problems with body image and BD (Presnell et al., 2004). This is especially common during adolescence as it is a time when conformity is important to gain approval from peers. However, it cannot be concluded if peer pressure certainly leads to developing disorders rather than just increasing the tendency to be dissatisfied with their body image or to diet.
A meta- analytic review of studies found significant evidence that perceived pressure to be thin is a causal risk factor for dieting, body dissatisfaction and bulimic symptoms (Stice, 2002). Nevertheless, these are not the only factors causing an ED, for example, it has been found that some people may believe that their body image is not resembling their ideal but are still satisfied with the fact (Polivy & Heman, 2002). Moreover, not everyone who diets develops an ED. This implies that there are other factors such as psychological or biological, which are required for BD and dieting to develop into a disorder.
Numerous studies have categorised personality traits that are typical of individuals with EDs, hence, it could be possible that there is an interaction between personality traits and risk factors which then leads to an ED. Personality traits include perfectionism, negative affect and low self- esteem. Perfectionism is the tendency to set and practice unrealistically high goals, while even being aware of the damaging consequences. Perfectionism could be self -oriented, which is when high standards are set for oneself, or it could be other- oriented which is when goals are set to conform to the standards set by others. Research has shown that people with EDs display greater levels of neurotic perfectionism and similar levels of normal perfectionism when compared to healthy controls (Ashby, Kottman, & Schoen, 1998). Furthermore, perfectionism has found to be the predictor of the onset of AN symptoms (Tyrka et al., 2002) and also bulimic symptoms in females who perceive themselves as overweight (Joiner et al., 1997). It is suggested that Negative affect plays a distinct role in the aetiology of EDs, people binge eat to be distracted from negative emotions and provide comfort (McCarthy, 1990). Inducing depressive feelings are known as negative affect inductions, and they produce a severe increase in body dissatisfaction (Stice, Little & Foerster, 2001). During negative mood conditions, there is an increase in food consumption in people who are dieting or who have an erroneous attitude towards eating. This suggests that negative mood may cause binging and purging patterns which are typical of BN sufferers. It has been argued whether negative mood is a cause of an ED or if it is merely a consequence, however, a recent meta- analysis found that ratings of negative affect were higher before binge eating episodes compared to ratings before regular eating episodes, these findings suggest that negative affect may be increased before binge eating (Haedt-Matt, 2011). Research has also established a relationship between obsessive- compulsive traits and EDs (Anderluh et al., 2003), obsessive- compulsive traits include checking, doubting and the need for exactness. Ample of research is presently suggesting a relationship between personality disorders (PD) and EDs, comorbidity between EDs and PDs ranges from estimates of 27- 93% (Vitousek & Manke 1994). However, it is important to note that most assessments of PDs are self -report thus have less validity. Furthermore, high rates of comorbidity between EDs and other psychiatric disorders have been found, for example, research has shown that a significant number of AN sufferers also have a diagnosis of major depression (Halmi et al., 1991).
Biological factors also play a role in the risk factors for developing an ED, biological theories suggest that certain genes may leave some people more vulnerable to developing an ED. First degree relatives with ED are more likely to develop a disorder than someone who has never been diagnosed with an ED. Twin studies have shown if an identical twin has AN, it is 70% likely for the other twin to also develop the disorder, while in fraternal twins the rate is 20%, as they are less genetically identical (Thornton et al., 2011). It is important to consider that classic twin studies reflect epigenetic effects, a gene- environment interaction, and do not only show genetic influence. This is evident in research that has shown shared environmental influences is greater than non-shared environments (Klump et al., 2009). However, twin studies are not a true representation, and the result may not be generalized to everyone. Neurobiological changes could also cause EDs, for example, endogenous opioids are compounds that the body releases during starvation. In AN, starvation may increase the levels of opioids thus producing a state of elation, and reinforcing self- starvation. Research has also found a link between low levels of serotionin and EDs (Kaye, 2011). Abnormal serotonin activity may cause craving and binge on high- carbohydrate foods.
Eating disorders has been characterised a culture- bound syndrome, which Prince (1985) defines as “a collection of signs and symptoms which is restricted to a limited number of cultures primarily by reason of certain of their psychosocial features”. He also suggested that this decision centres on the question if the syndrome occurs in non- Western cultures, a study by Keel and Klump (2003) found no studies reporting the presence of bulimia in cultures which were not exposed to Western ideals.
In terms of treatment for EDs, it would be beneficial to target the more general risk factors that have shown to predict several unfavourable outcomes because those interventions would result in better overall improvements in mental health. For example, findings suggest that BN and BED treatments should focus on reducing sociocultural influences such as the thin- ideal internalization, negative affect and body dissatisfaction (Stice, 2002). This could be carried out using Cognitive Behavioural Therapy (CBT) which is based on the trans -diagnostic model developed by Fairburn at al., 1999. The theory that supports CBT proposes that bulimic individuals negatively self- evaluate their eating and body shape, and develop thin- ideal internalization which then causes them to diet excessively, and because of this restriction they lapse into binge- eating. An episode of binging is followed by purging which then causes the individual to restrict their diet even further, and the whole process becomes a continuous cycle. The theory suggests that rather than focusing on the patients’ binge eating, their over evaluation and low self- esteem is of key importance in maintaining the disorder, as they are the initial steps of the cycle. There are three stages involved in CBT: the first stage involves helping the client identify the stimuli or events that may trigger a binge episode. Secondly, the individual’s body dissatisfaction and low self- esteem are addressed and replaced with more adaptive cognitions. The last stage involves developing relapse prevention methods by encouraging self- control procedures. While this method is suitable for bulimic patients only, a more ‘enhanced’ form has been developed which can be used in other EDs. It includes changes such as helping with an increase in motivation and weight gain, which is more suitable for AN patients. Ample of evidence s present to support the success of CBT, for example, a study found that 40-50% of treatment completers ceased binge eating and purging completely (Fairburn et al., 1995). However, research has found that individuals who are considered clinically recovered because they have ceased binge eating and purging still report substantial cognitive symptoms (Keski- Rahkonen et al., 2009). Hence, recent research has suggested that treatment success should not only be based on behavioural symptoms but also cognitive symptoms (Williams, Watts, & Wade, 2012).
As previously suggested, there is a strong comorbidity between ED and other psychiatric disorders, this could cause treatment to be difficult and complex as a combination of pharmacological and psychological treatments must be used. Nevertheless, research has shown that antidepressant drugs are more successful with BN than with AN, it was found that people that the drug helped 40% of people receiving it, reducing their binges by an average of 67% and vomiting by 56%, yet, drugs work better when combined with CBT (Stewart & Williamson, 2008).
Since risk factors could predict the emergence of ED, they could be used to identify high-risk groups for selective prevention programs. These intervention programs attempt to prevent the onset of a psychopathology before the primary symptoms are detected. The most effective prevention programmes are the ones which are most interactive and can direct individuals at high risk of developing an ED (Stice, Shaw & Marti, 2007). Appropriate programs should use a combination of several risk factors for assessment purposes, as this would help identify a higher risk population than a specific assessment scale would.
Clinicians face various challenges while treating patients with EDs, for example, some treatments require self- reports and research have shown that individuals with Ed have poor introspective skills and tend to deny symptoms in the self -report (Vitousek et al., 1991). Many bulimic individuals perceive their purging as a helpful method of controlling weight, while anorexic patients view their dieting as a beneficial activity. Furthermore, some individuals may be in denial, they may not see their disorder as harmful or may not accept they have a disorder in the first place.
A common treatment used with ED sufferers, particularly AN adolescents, is family therapy. It originates from the idea that sufferers must be surrounded by dysfunctional families that strongly promotes the development of ED. A classic example of family therapy explores the relationship and emotional concerns within the family alongside individual feelings. The Maudsley approach is a family based, staged therapy for eating disorders. It comprises of three stages: the first one focuses on the family’s problems and solutions, the second stage aids the family in tackling the ED symptoms, and lastly, family relations and activities are developed, once they have recovered from the symptoms of ED (Eisler, 2005). While there is supportive evidence for the effectiveness of family based therapy, there is limited research in a well-controlled treatment outcome (Cottrell, 2003).
In conclusion, eating disorders can have various risk factors, with an individual suffering from either one or a range of them. Risk factors can be used to choose the appropriate therapeutic intervention. There are various treatments available for ED, yet each one encompasses its own function.