Weight concern should not be a necessary criterion for the eating disorders: a polemic

Severe and Enduring Anorexia Nervosa: Enduring Wrong Assumptions?

To the extent that severe and lasting anorexia nervosa (SE-AN) is defined in terms of refractoriness to the best treatments available, it is mandatory to scrutinize the proven effectiveness of the treatments offered to patients. The array of so-called current evidence-based treatments for anorexia nervosa (AN) encompasses the entire spectrum of treatments ranging from specialized brand-type treatments to new treatments adapted to the specific characteristics of people suffering from AN. However, after several randomized control trials, parity in efficacy is the characteristic among these treatments. To further complicate the landscape of effective treatments, this "tie score" extends to the treatment originally conceived as control conditions, or treatment as usual conditions. In retrospection, one can understand that treatments considered to be the best treatments available in the past were unaware of their possible iatrogenic effects. Obviously, the same can be said of the theoretical assumptions underpinning such treatments. In either case, if the definition of chronicity mentioned above is applied, it is clear that the responsibility for the chronicity of the disorder says more about the flagrant inefficacy of the treatments and the defective assumptions underpinning them, than the nature of the disorder itself. A historical analysis traces the emergence of the current concept of "typical" AN and Hilde Bruch's contribution to it. It is concluded that today's diagnostic criteria resulting from a long process of acculturation distort rather than capture the essence of the disorder, as well as marginalizing and invalidating patients' perspectives.

Not all body image constructs are created equal: Predicting eating disorder outcomes from preoccupation, dissatisfaction, and overvaluation

OBJECTIVE

Diverse terminology has been used to operationalize body image disturbance in eating disorders. However, the differential validity of these terms and their underlying constructs to predict outcomes among heterogeneous eating disorders is unknown. This study evaluated the validity of body image constructs to predict eating disorder and negative psychological symptoms concurrently and prospectively over 2 years in a transdiagnostic clinical sample.

METHODS

Women with heterogeneous eating disorder diagnoses (n = 448) completed assessments at baseline, 12-month, and 24-month follow-up. Cross-sectional and cross-lagged generalized linear models examined effects of three body image constructs (i.e., weight and shape preoccupation, overvaluation, and dissatisfaction) on concurrent and subsequent outcomes (i.e., global eating disorder symptoms, binge eating, purging, fasting, self-esteem, and depression).

RESULTS

In concurrent analyses, preoccupation was significantly associated with all outcomes (ps = .01 to <.001), overvaluation with all outcomes (ps = .01 to <.001) except binge eating (p = .06), and dissatisfaction with all outcomes (ps < .001) except purging (p = .38). In prospective analyses, preoccupation predicted Eating Disorder Examination global (p = .003) and fasting (p < .001), overvaluation predicted binge eating (p = .01), and body dissatisfaction did not predict any outcomes.

DISCUSSION

Preoccupation, overvaluation, and dissatisfaction are differentially related to eating disorder and psychiatric outcomes, indicating that no one body image construct can capture clinical risk in eating disorders. Preoccupation was the most consistent concurrent and longitudinal predictor; this construct may warrant further attention in assessment and diagnosis. Further investigation of these constructs in diverse samples is encouraged.

Eating disorders in women

Eating disorders, especially anorexia nervosa and bulimia nervosa have been classically described in young females in Western population. Recent research shows that they are also seen in developing countries including India. The classification of eating disorders has been expanded to include recently described conditions like binge eating disorder. Eating disorders have a multifactorial etiology. Genetic factor appear to play a major role. Recent advances in neurobiology have improved our understanding of these conditions and may possibly help us develop more effective treatments in future. Premorbid personality appears to play an important role, with differential predisposition for individual disorders. The role of cultural factors in the etiology of these conditions is debated. Culture may have a pathoplastic effect leading to non-conforming presentations like the non fat-phobic form of anorexia nervosa, which are commonly reported in developing countries. With rapid cultural transformation, the classical forms of these conditions are being described throughout the world. Diagnostic criteria have been modified to accommodate for these myriad presentations. Treatment of eating disorders can be quite challenging, given the dearth of established treatments and poor motivation/insight in these conditions. Nutritional rehabilitation and psychotherapy remains the mainstay of treatment, while pharmacotherapy may be helpful in specific situations.

'No entry', an invitation to intrude, or both? Reflections on a group of anorexic patients

This paper describes the twice-weekly psychoanalytic psychotherapy of a young woman who had undergone major bowel surgery in her early 20s, with no clear medical indication for the surgery. Whilst the concept of 'No Entry' described by Williams (, b) aptly describes many features of more 'typical' anorexic patients, this paper describes a particular group of anorexic patients, referred by their physicians for multiple medical procedures; and proposes there is a group of anorexic patients, repeatedly referred for medical investigations, into whom particular types of entries occur. These are entries into the body 'legitimized' as medical, with a trajectory towards multiple procedures, examinations and surgical operations. Other entries (outside the medical setting) may occur in a state of altered consciousness, under the influence of alcohol or drugs, such that any wish for intrusion is disowned and denied. In both sets of events, intrusion is both invited, and consciously denied. The case example illuminates some of these features, and aspects of the countertransference are also described. Attention is drawn to relevant research focusing on surgical intrusion. Finally, there is an exploration as to how such patients may invite intrusions into the body through surgery and medical procedures.

Nonfat phobic anorexia nervosa: clinical characteristics and response to inpatient treatment

OBJECTIVE

The aim of this study was to compare patients admitted to a specialized inpatient program for anorexia nervosa (AN) with and without a fear of weight gain in terms of specific eating disorder symptoms, general psychopathology, and treatment outcome.

METHOD

Measures of specific and general psychopathology were administered at admission to and discharge from the inpatient program. Of the 138 participants, 81% (n = 112) were categorized as having clinical levels of "fear of weight gain" and 19% (n = 26) were categorized as having subclinical levels of this feature.

RESULTS

The subclinical-level group had lower scores on measures of eating disorder psychopathology, depression, general psychiatric disturbance, and obsessive-compulsive symptomatology, but higher self-esteem scores. There were no differences found in terms of age of onset of AN, duration of illness, AN subtype, body mass index, or treatment outcome.

DISCUSSION

The current findings provide evidence that underweight patients who deny a fear of weight gain are less disturbed in terms of both eating disorder pathology and general psychopathology.

Reduced body size and shape-related symptoms in young adults born preterm with very low birth weight: Helsinki study of very low birth weight adults

OBJECTIVE

To test the hypothesis that being born prematurely with very low birth weight (VLBW) (birth weight<or=1500 g) is associated with subphenotypes of eating disorders (dissatisfaction with body shape and pursuit of thinness) in young adulthood.

STUDY DESIGN

Preterm-born VLBW subjects (n=163) and controls (n=189) born at term completed 3 subscales of Eating Disorder Inventory-2 questionnaire (EDI): Drive for Thinness, Body Dissatisfaction, and Bulimia. Data were analyzed with multiple linear regression adjusted for confounders.

RESULTS

Among both sexes, EDI total scores were lower in VLBW subjects than in controls. The fully adjusted difference was -11.0% (95% CI, -18.4%, -2.2%) for women and -11.2% (95% CI, -20.2%, -1.3%) for men. Among women the lower scores in VLBW adults were observed in each EDI subscale. Results were similar when adjusted also for fat percentage, measured by dual-energy x-ray absorptiometry. Of the covariates, higher body mass index and higher score in Beck Depression Inventory contributed significantly to a higher EDI total score.

CONCLUSIONS

Young adults, particularly women, born prematurely with VLBW have fewer body size and shape-related symptoms and possibly lower risk for eating disorders than their term-born peers.

Should non-fat-phobic anorexia nervosa be included in DSM-V?

OBJECTIVE

Cross-cultural data suggest that rationales for food refusal vary in anorexia nervosa (AN), and a variant, termed non-fat-phobic AN (NFP-AN), has been described. This review evaluates whether data support modification of the requirement for intense fear of weight gain to meet AN criterion B in DSM-V.

METHOD

We performed a systematic search of the Medline and PsychInfo literature and evaluated the relevant publications by Robins and Guze's (Am J Psychiatry 126, 983-987, 1970) criteria as a standard for diagnostic validity. We also performed a meta-analysis comparing the severity of eating pathology in AN to (a) NFP-AN and (b) AN with low drive for thinness (low-DT-AN).

RESULTS

A modest literature indicates that NFP-AN has wide geographic distribution and occurs in both Western and non-Western populations alongside cases of typical AN. Aggregating across eligible studies, patients with NFP-AN or low-DT-AN score at least 2/3 of a standard deviation lower on measures of eating pathology than patients with conventional AN. Transcultural comparison of drive for thinness suggests significantly lower norms in non-Western cultures.

DISCUSSION

NFP-AN occurs with wide distribution. Further research is necessary on the course and outcomes of NFP-AN to characterize its congruence with, or distinction from, conventional AN. We discuss several options for including a description of NFP-AN in DSM-V.

Eating disorder not otherwise specified in an inpatient unit: the impact of altering the DSM-IV criteria for anorexia and bulimia nervosa

OBJECTIVE

To evaluate (1) the Eating Disorder Not Otherwise Specified (EDNOS) prevalence in an eating disorder inpatient unit; (2) the impact of altering the diagnostic criteria for anorexia nervosa and bulimia nervosa on the prevalence of EDNOS.

METHOD

One hundred and eighty six eating disorder patients consecutively hospitalised were included in the study. The prevalence of anorexia nervosa, bulimia nervosa and EDNOS was evaluated with the Eating Disorder Examination (EDE). The EDNOS prevalence was recalculated after the alteration of three diagnostic criteria for anorexia nervosa and one for bulimia nervosa.

RESULTS

Seventy eight patients (41.9%) met the diagnostic criteria for anorexia nervosa, 33 (17.8%) for bulimia nervosa and 75 (40.3%) for EDNOS. The alteration of the DSM-IV diagnostic criteria reduced the prevalence of EDNOS to 28 cases (15%).

CONCLUSION

EDNOS is a very frequent diagnostic category in an inpatient setting. Altering the diagnostic criteria for anorexia nervosa and bulimia nervosa reduced significantly the prevalence of EDNOS.

Restraint and eating concern in North European and East Asian women with and without eating disorders in Australia and Singapore

OBJECTIVE

To investigate eating disorder psychopathology, restraint and eating concern in young women with and without an eating disorder from two different ethnic groups in Australia and Singapore.

METHOD

The relationship of Eating Disorder Examination Questionnaire Global, Restraint and Eating Concern scores to cultural orientation and sociocultural factors was analysed in 154 women with and without an eating disorder. Participants were from the following backgrounds: North European Australian, East Asian Australian, Singaporean Chinese and North European expatriates in Singapore.

RESULTS

Women with eating disorders had similar psychopathology across the cultural groups. Among controls, Singaporean Chinese reported significantly greater overall eating disorder psychopathology than other cultural groups and greater restraint than North European Australians/expatriates. Eating concern was not associated with cultural group overall or acculturation to Western culture. Dissatisfaction with family functioning, socioeconomic status and education level were not significantly associated with any of the eating disorder measures.

CONCLUSION

In eating disorder psychopathology, the specific symptom of eating concern may transcend cultural influences.

The severity and status of eating disorder NOS: implications for DSM-V

"Eating disorder NOS" is the most common eating disorder encountered in outpatient settings yet it has been neglected. The aim of this study was to describe the characteristics of eating disorder NOS, establish its severity, and determine whether its high relative prevalence might be due to the inclusion of cases closely resembling anorexia nervosa or bulimia nervosa. One hundred and seventy consecutive patients with an eating disorder were assessed using standardised instruments. Operational DSM-IV diagnoses were made and eating disorder NOS cases were compared with bulimia nervosa cases. Diagnostic criteria were then adjusted to determine the impact on the prevalence of eating disorder NOS. Cases of eating disorder NOS comprised 60.0% of the sample. These cases closely resembled the cases of bulimia nervosa in the nature, duration and severity of their psychopathology. Few could be reclassified as cases of anorexia nervosa or bulimia nervosa. The findings indicate that eating disorder NOS is common, severe and persistent. Most cases are "mixed" in character and not subthreshold forms of anorexia nervosa or bulimia nervosa. It is proposed that in DSM-V the clinical state (or states) currently embraced by the diagnosis eating disorder NOS be reclassified as one or more specific forms of eating disorder.

The comparative utility of statistically derived eating disorder clusters and DSM-IV diagnoses: relationship to symptomatology and psychiatric comorbidity at intake and follow-up

INTRODUCTION

The classification of eating disorders has been a matter of considerable debate. The present paper extends previous work and aimed to compare the utility of statistically derived clusters of eating disorders and conventional diagnoses.

METHODS

Adult female eating disorder patients who had previously been classified on the basis of cluster analysis of key diagnostic variables were examined on measures of eating disorder symptomatology and psychiatric comorbidity at intake (N=601) and subsequent follow-up after 6 and 36 months (N=349, N=322, respectively).

RESULTS

Compared to DSM-IV diagnoses, clusters demonstrated greater utility in terms of more distinct between-group differences and higher effect sizes in relation to a wide range of variables. The greater utility of clusters was in important respects due to the reallocation of EDNOS patients to more relevant alternative categories and to a greater emphasis on psychological and behavioural features of eating disorders.

CONCLUSIONS

In order to achieve a better classification of eating disorders, it will be important to place increased emphasis on common psychological features. There is a need to move away from increased use of subtypes and toward a definition of eating disorder per se.

Are eating disorders culture-bound syndromes? Implications for conceptualizing their etiology

The authors explore the extent to which eating disorders, specifically anorexia nervosa (AN) and bulimia nervosa (BN), represent culture-bound syndromes and discuss implications for conceptualizing the role genes play in their etiology. The examination is divided into 3 sections: a quantitative meta-analysis of changes in incidence rates since the formal recognition of AN and BN, a qualitative summary of historical evidence of eating disorders before their formal recognition, and an evaluation of the presence of these disorders in non-Western cultures. Findings suggest that BN is a culture-bound syndrome and AN is not. Thus, heritability estimates for BN may show greater variability cross-culturally than heritability estimates for AN, and the genetic bases of these disorders may be associated with differential pathoplasticity.

Development of weight and shape concerns in the aetiology of eating disorders

BACKGROUND

Although weight and shape concerns are considered to be integral to the psychopathology of anorexia and bulimia nervosa, uncertainties remain about developmental aspects of the aetiology of these concerns and their relationship to eating disorders.

AIMS

To review the recent literature on weight and shape concern, with particular emphasis on aetiology, to identify a possible developmental pathway from weight concern through abnormal eating behaviour to disorder.

METHOD

Literature review of Medline and Psychlit databases using the keywords 'eating disorder', 'weight concern', 'shape concern' and 'aetiology'. Inclusion criteria were based on the strength of quantitative research findings, originality of ideas and recent publication.

RESULTS

Weight and shape concerns follow a developmental pathway arising before the typical age for the development of eating disorders. The origins are multifactorial, with biological, family and sociocultural features predominating.

CONCLUSIONS

Although weight and shape concern seems commonly to underlie the development of eating disorders, an alternative pathway appears to exist through impulsivity and fear of loss of control. Prevention strategies may usefully focus on the attitudes and concerns that lead to dieting behaviour.

Cross-Cultural Research on Anorexia Nervosa: Assumptions Regarding the Role of Body Weight

OBJECTIVE

To critically examine two assumptions guiding cross-cultural research on the weight concerns of anorexia nervosa: (1) that weight concerns are specific to contemporary, Western manifestations of the disorder and (2) that the dissemination of Western values regarding thinness is primarily responsible for the development of anorexia nervosa in non-Western contexts.

METHOD

A review of theoretical and empirical literature on cross-cultural aspects of anorexia nervosa and the medical records of 14 Asian patients treated for eating disorders in Sydney, Australia.

RESULTS AND DISCUSSION

Regarding the first assumption: It is argued that weight concerns when defined as weight loss that is positively valued (rather than a fat phobia) is a defining characteristic of anorexia nervosa and is not limited to contemporary, Western cases of the disorder. Regarding the second assumption: It is argued that the occurrence of anorexia nervosa in non-Western contexts cannot be solely attributed to the acceptance of Western thinness ideals because values and practices intrinsic to non-Western cultures are also likely to be etiologically relevant.

Influence of shape and weight on self-evaluation in bulimia nervosa

OBJECTIVE

To compare three related but different measures of excessive concerns about shape and weight in bulimia nervosa (BN): influence of shape and weight (influence; DSM-IV Criterion D), overconcern with shape and weight (overconcern; DSM-III-R Criterion E), and dissatisfaction with shape and weight (dissatisfaction).

METHOD

One-hundred twenty BN patients, 27 restrained eaters (RE), and 28 normal controls (NC) were assessed via the Eating Disorders Examination and self-report measures.

RESULTS

Influence and overconcern, but not dissatisfaction, successfully discriminated BNs from NCs but not from REs. A minority of patients with BN obtained low scores on both influence and overconcern. However, there were few differences between those patients with low scores and those with high scores on numerous clinical characteristics.

DISCUSSION

Influence and overconcern are equally valid measures of the excessive concerns about shape and weight characteristic of BN.

Multidimensionality in adolescent eating problems. A two-phase measurement study

The aims of this study were, firstly, to examine the factor structure of single items from several self-report methods used to measure eating disorder symptoms, and secondly, in search for a short assessment instrument to reduce the number of items within each factor. Factor analyses were employed to identify and confirm the constructs measured by a total of sixty items drawn from these assessment methods. In phase one, 508 secondary school pupils were recruited as subjects, and principal factor analysis identified three factors; body concern, dieting, and loss of control over eating. Twenty-nine items were retained, and in phase two subjected to a second data collection among 4129 secondary school pupils. Confirmatory factor analysis was employed to cross-validate the factor structure from phase one. The three-factor structure was confirmed satisfactorily for boys, but not for girls aged 12-14 years. For girls aged 14-16 years, it was confirmed when a number of items were omitted. The findings are discussed in relation to restraint theory and the continuum hypothesis.

Atypical anorexia nervosa: separation from typical cases in course and outcome in a long-term prospective study

OBJECTIVE

To assess differences in long-term course and outcome between typical and atypical cases of anorexia nervosa.

METHOD

A naturalistic, longitudinal prospective design was used to assess recovery, relapse, and onset of binge eating over 10 to 15 years in patients ascertained through a university-based specialty treatment program. Atypical anorexia nervosa was distinguished from the diagnostically prototypic form of the disorder based on the continuous absence of morbid fear of weight gain and body size distortion during the inpatient phase of treatment. Patients were assessed semiannually for 5 years then annually thereafter until the final visit.

RESULTS

Compared to pure cases of anorexia nervosa, atypical cases were less likely to drop weight after discharge, recovered more rapidly, and had lower cumulative risk for developing binge eating.

CONCLUSION

It has been argued recently that weight phobia and body image disturbance should not be viewed as critical to the diagnosis of anorexia nervosa. This study shows that the absence of these particular symptoms in patients presenting with malnutrition secondary to extreme dietary restriction predicts a less malignant course and outcome compared to typical cases of anorexia nervosa. These course differences suggest that the division of patients into typical versus atypical diagnostic subtypes may be nosologically valid and clinically useful.

A cognitive behavioural theory of anorexia nervosa

A cognitive behavioural theory of the maintenance of anorexia nervosa is proposed. It is argued that an extreme need to control eating is the central feature of the disorder, and that in Western societies a tendency to judge self-worth in terms of shape and weight is superimposed on this need for self-control. The theory represents a synthesis and extension of existing accounts. It is 'new', not so much because of its content, but because of its exclusive focus on maintenance, its organisational structure and its level of specification. It is suggested that the theory has important implications for treatment.

The EAT speaks many languages: review of the use of the EAT in eating disorders research

The Eating Attitudes Test questionnaire (EAT) has been a major instrument for detecting eating morbidity in a great number of studies across the world. The instrument was devised by two Canadian research workers and was initially validated on a Canadian population. Since then it has been used with reasonable success in eating disorders research emanating from English speaking countries, particularly the UK. This paper attempts to focus on the application of the EAT in non-English speaking countries where it was essential to translate it into the language of these countries. Comparative analysis of the results is assessed and the degree of success of the instrument in these studies is evaluated. The outcome of this review could have significant implications for the future use of the EAT in eating disorders research.

Self-starvation in context: towards a culturally sensitive understanding of anorexia nervosa

Extreme forms of self-starvation can be traced across time and place, and may be construed using a variety of explanatory models. Curiously, the prevailing biomedical definition of anorexia nervosa has assigned primacy to the exclusive use of 'fat phobia' by the affected subjects to justify their diminished food intake. This paper assembles evidence to show that this culturally constructed version of fat phobic anorexia nervosa has neglected the full metaphorical significance of self-starvation and, when applied in a cross-cultural context, may constitute a category fallacy. By delegitimizing other rationales for non-eating and thereby barring subjective expressions, this regnant interpretive strategy may obscure clinicians' understanding of patients' lived experience, and even jeopardize their treatment. Nonetheless, it is a relatively simple task to attune the extant diagnostic criteria to a polythetic approach which will avert cultural parochialism in psychiatric theory and practice. As a corollary of the archival and ethnocultural study of extreme self-starvation, there is, contrary to epistemological assumptions embedded in the biomedical culture of contemporary psychiatry, no 'core psychopathology' of anorexia nervosa.

Eating disorders: an Indian perspective

Anorexia nervosa and related eating disorders are rare in non-western cultures. In India the information regarding these disorders is very limited. The authors describe five cases of young women who chiefly presented with refusal to eat, persistent vomiting, marked weight loss, amenorrhea and other somatic symptoms. They did not show overactivity or disturbances in body image seen characteristically in anorexia nervosa. Though finally diagnosed and treated as cases of eating disorder, they presented considerable difficulty in diagnosis. The paper discusses the reasons for the seeming rarity of anorexia nervosa in India and sociocultural reasons for its atypical presentation.