How do people with eating disorders experience the stigma associated with their condition? A mixed-methods systematic review

Exploring Biases of Large Language Models in the Field of Mental Health: Comparative Questionnaire Study of the Effect of Gender and Sexual Orientation in Anorexia Nervosa and Bulimia Nervosa Case Vignettes

Background

Large language models (LLMs) are increasingly used in mental health, showing promise in assessing disorders. However, concerns exist regarding their accuracy, reliability, and fairness. Societal biases and underrepresentation of certain populations may impact LLMs. Because LLMs are already used for clinical practice, including decision support, it is important to investigate potential biases to ensure a responsible use of LLMs. Anorexia nervosa (AN) and bulimia nervosa (BN) show a lifetime prevalence of 1%-2%, affecting more women than men. Among men, homosexual men face a higher risk of eating disorders (EDs) than heterosexual men. However, men are underrepresented in ED research, and studies on gender, sexual orientation, and their impact on AN and BN prevalence, symptoms, and treatment outcomes remain limited.

objectives

We aimed to estimate the presence and size of bias related to gender and sexual orientation produced by a common LLM as well as a smaller LLM specifically trained for mental health analyses, exemplified in the context of ED symptomatology and health-related quality of life (HRQoL) of patients with AN or BN.

Methods

We extracted 30 case vignettes (22 AN and 8 BN) from scientific papers. We adapted each vignette to create 4 versions, describing a female versus male patient living with their female versus male partner (2 × 2 design), yielding 120 vignettes. We then fed each vignette into ChatGPT-4 and to "MentaLLaMA" based on the Large Language Model Meta AI (LLaMA) architecture thrice with the instruction to evaluate them by providing responses to 2 psychometric instruments, the RAND-36 questionnaire assessing HRQoL and the eating disorder examination questionnaire. With the resulting LLM-generated scores, we calculated multilevel models with a random intercept for gender and sexual orientation (accounting for within-vignette variance), nested in vignettes (accounting for between-vignette variance).

Results

In ChatGPT-4, the multilevel model with 360 observations indicated a significant association with gender for the RAND-36 mental composite summary (conditional means: 12.8 for male and 15.1 for female cases; 95% CI of the effect -6.15 to -0.35; P=.04) but neither with sexual orientation (P=.71) nor with an interaction effect (P=.37). We found no indications for main effects of gender (conditional means: 5.65 for male and 5.61 for female cases; 95% CI -0.10 to 0.14; P=.88), sexual orientation (conditional means: 5.63 for heterosexual and 5.62 for homosexual cases; 95% CI -0.14 to 0.09; P=.67), or for an interaction effect (P=.61, 95% CI -0.11 to 0.19) for the eating disorder examination questionnaire overall score (conditional means 5.59-5.65 95% CIs 5.45 to 5.7). MentaLLaMA did not yield reliable results.

Conclusions

LLM-generated mental HRQoL estimates for AN and BN case vignettes may be biased by gender, with male cases scoring lower despite no real-world evidence supporting this pattern. This highlights the risk of bias in generative artificial intelligence in the field of mental health. Understanding and mitigating biases related to gender and other factors, such as ethnicity, and socioeconomic status are crucial for responsible use in diagnostics and treatment recommendations.

Equity in eating disorders: a dialectical approach to stigma, expertise, and the coproduction of knowledge

Within mental health research, there has been a growing recognition of the importance of the knowledge obtained through lived experiences of illness, treatment, recovery, and health. In recent years, the field of eating disorders has seen an emergence of co-produced knowledge, in particular in the co-design of patient-facing materials for use in clinical settings, and a growing body of rich qualitative research by those who may straddle the identities of clinician, researcher and person with lived/living experience. However, there are significant variations in how expertise by experience is defined and utilised within research and clinical practice, and persisting inequities in the extent to which people with lived experience are afforded the agency to define their illnesses and treatment. This paper's authorship is a collaboration between those with personal and professional relationships with the subject of eating disorders, bringing to life the concept of sharing power and decision-making across multiple viewpoints and identities. Situating knowledge about eating disorders and stigma within a wider historical and philosophical context, the authors argue that persisting inequities in research and clinical practice are rooted in multiple stigmas. To address this, a 'dialectical' stance is proposed, which draws upon Dialectical Behaviour Therapy and broader principles of coproduction to offer a practical approach to operationalising epistemic justice and dismantling stigma in the field.

The current clinical approach to feeding and eating disorders aimed to increase personalization of management

Feeding and eating disorders (FEDs) are a heterogeneous grouping of disorders at the mind-body interface, with typical onset from childhood into emerging adulthood. They occur along a spectrum of disordered eating and compensatory weight management behaviors, and from low to high body weight. Psychiatric comorbidities are the norm. In contrast to other major psychiatric disorders, first-line treatments for FEDs are mainly psychological and/or nutrition-focused, with medications playing a minor adjunctive role. Patients, carers and clinicians all have identified personalization of treatment as a priority. Yet, for all FEDs, the evidence base supporting this personalization is limited. Importantly, disordered eating and related behaviors can have serious physical consequences and may put the patient's life at risk. In these cases, immediate safety and risk management considerations may at least for a period need to be prioritized over other efforts at personalization of care. This paper systematically reviews several key domains that may be relevant to the characterization of the individual patient with a FED aimed at personalization of management. These domains include symptom profile, clinical subtypes, severity, clinical staging, physical complications and consequences, antecedent and concomitant psychiatric conditions, social functioning and quality of life, neurocognition, social cognition and emotion, dysfunctional cognitive schemata, personality traits, family history, early environmental exposures, recent environmental exposures, stigma, and protective factors. Where possible, validated assessment measures for use in clinical practice are identified. The limitations of the current evidence are pointed out, and possible directions for future research are highlighted. These also include novel and emerging approaches aimed at providing more fine-grained and sophisticated ways to personalize treatment of FEDs, such as those that utilize neurobiological markers. We additionally outline remote measurement technologies designed to delineate patients' illness and recovery trajectories and facilitate development of novel intervention approaches.

Comparing social stigma of anorexia nervosa, bulimia nervosa, and binge-eating disorder: A quantitative experimental study

BACKGROUND

Currently, we know little regarding how stigma attributed to eating disorders compares to that of other psychological disorders and additionally within different types of eating disorders. In the current study, we aimed to explore the stigmatisation of eating disorders by comparing the stigma attributed to anorexia nervosa, bulimia nervosa, and binge-eating disorder, utilising depression as a comparative control.

METHODS

A total of 235 participants from the general population were randomly assigned to an anorexia nervosa, bulimia nervosa, binge-eating disorder, or depression condition. Participants responded to a questionnaire consisting of several adapted versions of pre-existing subscales that measured levels of stigma associated with psychological disorders generally, as well as stigma associated with eating disorders specifically. We used several one-way analyses of variance to investigate the differences in stigma attributed towards the aforementioned psychological disorders.

RESULTS

Results suggested that all three eating disorders were significantly more stigmatised than was depression. Between the eating disorders, the three were generally equivalent except that binge-eating disorder was significantly more stigmatised than both anorexia nervosa and bulimia nervosa on a subscale measuring trivialness.

CONCLUSIONS

These findings indicate that individuals with eating disorders, including binge-eating disorder, may be at a higher risk of experiencing the negative implications of stigma when compared to other psychological disorders, such as depression. To our knowledge, this study is one of few that directly quantify and compare stigma attributed towards anorexia nervosa, bulimia nervosa, and binge-eating disorder. Through further research, a better understanding around the expression of stigma towards specific eating disorders could inform the development of targeted interventions to help reduce the stigma associated with these disorders. This knowledge could also advance the understanding of the lived experience of individuals living with eating disorders, subsequently informing treatment practices.

The healthy eating movement on social media and its psychological effects on body image

Introduction

The present study aims to investigate the relationship between social-media pressure, the tendency to internalize standards of beauty and attractiveness associated with thin bodies, which subsequently leads to distortion of body shape perceptions, and restrictive and emotional eating behavior disorders.

Methods

A survey-based research design was employed, utilizing an online questionnaire to collect data. The study sample consisted of 614 students, selected from the most prestigious universities in Bucharest. The questionnaire incorporated validated scales measuring Socio-Media Pressure for a Thin Body Image (SMPTB), Body Appreciation (BA), Body Shape Perception (BSP), Restrained Eating Behavior (REB), and Emotional Eating Behavior (EEB).

Results

The results confirmed the hypotheses of the research, meaning food restrictions are a way to diminish the level of dissatisfaction with body shape, to reduce the difference between the ideal body shape and the real one. Food restrictions are perceived as natural behaviors, appropriate to support the standards of beauty and attractiveness specific to this historical stage. Emotional eating disorders emerge as a way to compensate for the discomfort generated by low body esteem.

Discussion

The results underscore the pervasive influence of social media in shaping eating behaviors and body image perceptions. Food restrictions, framed as natural responses to societal pressures, highlight the need for interventions addressing the normalization of harmful beauty standards. Emotional eating behaviors reveal the psychological toll of body dissatisfaction, emphasizing the importance of strategies to foster positive body image and mental well-being. These findings provide a foundation for developing educational campaigns and therapeutic approaches targeting the psychological impact of social media on eating behaviors.

Two identical twin pairs discordant for longstanding anorexia nervosa and OSFED: lived experience accounts of eating disorder and recovery processes

Research into the risk of anorexia nervosa (AN) has examined twin pairs to further the understanding of the contributions of genetics, trait inheritance, and environmental factors to eating disorder (ED) development. Investigations of twin experiences of EDs have been biologically-based and have not considered the qualitative, phenomenological aspects of twin experiences. A gap in the literature exists regarding understanding of discordant twins with EDs. This research was developed in response, with the aim to deepen understanding of AN in discordant twins and to create novel ideas for further research and testing. The case studies presented in this article provide lived experience insights of two identical discordant twin pairs: one twin pair discordant for longstanding AN and one twin pair discordant for 'atypical' AN (the twin with AN has recovered). The perspectives and experiences of each co-twin (one with AN and one without) explore a number of factors that may have contributed to twin discordance in these cases, and how each twin has responded to the impact of AN in their lives. Through use of first-person accounts in case study presentation, this article centres social justice values of lived experience leadership and involvement in research. This article aims to extend current knowledge and understanding of EDs in discordant twins, particularly regarding risk for ED development, ED duration, diagnosis and treatment, and recovery processes.

A Narrative Review of Early Intervention for Eating Disorders: Barriers and Facilitators

Eating disorders (EDs) are serious psychiatric illnesses that typically develop during adolescence and emerging adulthood. Early intervention is important for improved outcomes for young people with EDs, yet help-seeking is low and individuals often have a significantly protracted start to treatment, suggesting that early intervention is not well established in the ED field. Previous reviews on facilitators and barriers to early intervention for EDs largely cover perceived barriers related to patient variables and perspectives, whereas clinician-, service-, and healthcare system-related facilitators and barriers are less frequently reviewed. The aim of this review is to synthesize the literature on barriers to and facilitators of early intervention for EDs, regarding patient-, clinician-, service-, and healthcare system-related factors. A narrative review was conducted by searching for relevant peer-reviewed, English-language articles published up until July 2023 on PubMed and PsychINFO. The search was conducted in two steps. First, key search terms were used to identify existing reviews and meta-analyses on facilitators and barriers to early intervention for EDs. Then, additional search terms were added to search for primary and secondary research on patient/family, clinician, service, and healthcare system-related barriers and facilitators. The identified literature shows that, after overcoming intrinsic, motivational barriers (such as self-stigma, denial, and ambivalence), help-seeking individuals may be met with long service waiting lists and limited treatment options. Despite these barriers, there is ongoing research into early intervention in practice, which aims to reach underserved populations and facilitate early intervention despite high service demands and shortages of trained healthcare professionals. Funding for ED research and services has historically been low, and there is also a research-practice gap. This highlights the need for increased consideration of, and funding for early intervention for EDs, to remove barriers as well as facilitate discussions around how to make early intervention programs scalable and sustainable.

Scientific Publication Patterns of Systematic Reviews on Psychosocial Interventions Improving Well-being: Bibliometric Analysis

Background

Despite numerous empirical studies and systematic reviews conducted on the effectiveness of interventions improving psychological well-being, there is no holistic overview of published systematic reviews in this field.

Objective

This bibliometric study explored the scientific patterns of the effectiveness of different psychosocial interventions improving well-being among various categories of individuals with mental and physical diseases, to synthesize well-being intervention studies, and to suggest gaps and further studies in this emerging field.

Methods

The bibliometric analysis included identifying the most productive authors, institutions, and countries; most explored fields and subjects of study; most active journals and publishers; and performing citation analysis and analyzing publication trends between 2014 and 2022. We focused on data retrieved from known databases, and the study was conducted with a proven bibliometric approach.

Results

In total, 156 studies were found concerning the research domains and retrieved using LENS software from high-ranking databases (Crossref, Microsoft Academic, PubMed, and Core). These papers were written in English by 100 authors from 24 countries, among which, the leading country was the United Kingdom. Descriptive characteristics of the publications involved an increased number of publications in 2017 (n=35) and 2019 (n=34) and a decreased number in 2021 (n=4). The top 2 leading authors by citation score are James Thomas (3 papers and 260 citations) and Chris Dickens (3 papers and 182 citations). However, the most cited study had 592 citations. BMJ Open (n=6 articles) is the leading journal in the field of medicine; Clinical Psychology Review (n=5), in psychology; and Frontiers in Psychology, in psychological intervention (n=5) and psychology (n=5). The top 2 publishers were Wiley (n=28) and Elsevier (n=25).

Conclusions

This study indicates an overall interest in the declared domains within the last decade. Our findings primarily indicate that psychosocial interventions (PIs) were evaluated as being effective in managing mental and physical problems and enhancing well-being. Cognitive behavioral therapy was assessed as being effective in treating anxiety, psychoeducation in relapse prevention, and gratitude interventions in improving overall health, and the mindfulness approach had a positive impact on decreasing distress and depression. Moreover, all these intervention types resulted in an overall increase in an individuals’ well-being and resilience. Integrating social and cultural factors while considering individual differences increases the efficiency of PIs. Furthermore, PIs were evaluated as being effective in managing symptoms of eating disorders, dementia, and cancer. Our findings could help provide researchers an overview of the publication trends on research domains of focus for further studies, since it shows current findings and potential research needs in these fields, and would also benefit practitioners working on increasing their own and their patients' well-being.

Separating binge-eating disorder stigma and weight stigma: A vignette study

OBJECTIVE

Vignette research on binge-eating disorder (BED) stigma is limited and lacking methodological rigor. Existing studies lack control vignettes and typically present characters with overweight or obesity, introducing the confound of weight stigma. This study examined BED stigma while addressing these limitations.

METHOD

Participants (N = 421) were assigned to read one of six vignettes describing a woman with either BED or no BED as well as either no mention of weight, a recommended weight, or an obese weight. Four questionnaires examined personality stereotypes, emotional reactions to the character, desire for social distance from the character, and blame attributions.

RESULTS

The character with BED was ascribed more negative personality characteristics and faced less positive emotional reactions than the character without BED, regardless of weight status. However, BED stigma did not emerge for social distance or blame attributions. Regarding weight stigma, evidence was limited and moderated by the presence of BED, suggesting no additive effect between BED stigma and weight stigma. In fact, blame attributions toward the character with obesity were reduced by the presence of BED.

DISCUSSION

The results reveal that BED is a highly stigmatized eating disorder and suggest that weight stigma may be driven by assumptions about a person's eating behavior rather than their body size per se. Future studies must consider the relationship between BED stigma and weight stigma when assessing either form of stigma. The results also indicate new information to be integrated into anti-weight stigma campaigns as well as policy and public health initiatives.