Module 2

Sociocultural Impacts on Eating

Disorders
• If the pursuit of thinness in women has causal significance for anorexia,
then the recent cultural shift in the aesthetic ideal for women towards a
thinner body shape could be one factor accounting for the increased
prevalence of the disorder.
• The impact of the media in establishing role models cannot be
overemphasized.

• 60% - 70% of high school girls were dissatisfied with their bodies and
wanted to lose weight; by contrast, males wanted to gain.
• For North American women, higher social class has been strongly related
to thinness and dieting
• A century ago Fenwick (1880) commented that anorexia was more
common in 'the wealthier classes of society than amongst those who
have to procure their bread by daily labour'
• Anorexia is more common in females, and usually develops during
adolescence
 Multidetermined Disorder
• Anorexia may be viewed as a multidetermined
disorder with individual, family and possible cultural
predisposing factors.
• There is an interaction between 'mounting concerns
with shape' and psychopathology which pushes certain
vulnerable adolescents to behaviours which lead to
anorexia
• It could be hypothesized that subcultures in which
pressures to be slim and diet are prevalent may give
rise to a greater expression of anorexia in vulnerable
adolescents.
 Study
• Anorexia and excessive dieting concerns are overrepresented in dance and
modelling students (with dance students having the greatest frequency of
anorexia)
• The dancers from the more competitive dance schools weighed
significantly less than those from the less competitive school. Also, the
dancers weighed less than other adolescents in other competitive
environments
• This study supports the hypothesis that individuals who must focus
increased attention on a slim body shape are at risk for anorexia

• Alternatively, it is possible that persons at high risk of developing anorexia

may have been preferentially selected into the dance and modelling
groups.
• Within the dance sample there was a higher risk for anorexia nervosa in
those programs in which there was greater pressure to succeed as a
professional.
 Societal Pressures on Women
• Others have conceptualized anorexia as a 'weight phobia' or 'desire to be thin'; it
has been suggested that the 'need to grow thinner' is 'the sole motive force'
involved in its expression.

• Palazzoli (1974) felt that women must maintain traditional standards for
attractiveness while also rapidly assimilating the heightened demands for
professional performance and success.
• Boskind-Lodahl (1976) interpreted the anorexic's symptoms as a reflection of
contemporary women's often desperate striving to please others and validate
their self-worth by controlling their appearance.
• Bruch (1978) described the struggle to live up to perfectionistic or unrealistic
performance standards to be characteristic of people with anorexia

• The pressure for thinness when augmented by high performance expectations is

the ideal social medium for the expression of anorexia in vulnerable adolescents.
 ‘Thin Fat’
• Is anorexia a distinct entity or is it simply an extreme form of a
relatively common dieting disorder?
• Bruch (1973) has used the term 'thin fat' syndrome to describe
individuals with the psychological characteristics of anorexia but
without significant weight loss.

• Should they be seen as having a mild variant of anorexia, or are

they simply women at a low body weight, suffering from the effects
of undernutrition? Are they qualitatively or quantitatively different
from anorexics, or some combination of magnitude and 'like type'
differences?

• There is insufficient evidence at present to resolve the question of

whether anorexia is an extreme point on a continuum or a
qualitatively distinct entity.
 Predisposing Characteristics for
Anorexia
• Individual predisposing characteristics for anorexia: personality characteristics,
perceptual-conceptual disturbances, and a proclivity towards overweight or early
maturity.
• Family predisposing characteristics: interaction patterns, personality features in
parents and parental attitudes towards weight control, shape or fitness
• Hypothesis: many people possess the individual, familial or cultural antecedents
and that these become pathogenic within the context of stressors which initiate
dieting, weight loss and pursuit of thinness.

• Precipitants such as interpersonal separation or loss, sexual conflicts, heightened

achievement demands or distressing pubertal shape changes have been
identified in some cases, but the onset may be triggered by an apparently
innocuous event or comment leading to the 'fixed idea' that weight loss will
eliminate feelings of ineffectiveness or inadequacy.

• Weight loss can assume a functional role within a disturbed family. It can also
provide temporary relief from the stress associated with pubertal shape changes
or exemption from overwhelming achievement demands.
 Self-Schema
• The self-concept has been implicated as a important
determinant of eating disorders
• Self Concept theory: a limited collection of positive self-
schemas available in memory, in combination with a
chronically and inflexibly accessible body-weight self-
schema, lead to the disordered behaviors associated with
anorexia and bulimia.
• For both disorders, deviations in the self-concept have
been thought to play a pivotal role in the cause
• Bruch (1973) argued that the pathological pursuit of
thinness in anorexia stems from an impaired identity
formation in adolescence and a lack of clarity in the
definition of the self.
 Relationship between Anorexia and
Bulimia
• The nature of the relationship between anorexia and
bulimia remains unclear.
• Some theorists view them as part of a continuum of eating
disorders in which patterns of severe dietary restriction
eventually leads to binge/purging cycles
• Others suggest a distinct division between the two
disorders arguing that they are marked by unique
personality profiles and causes
• More recent approaches propose that there are three
subpopulations of women with an eating disorder
including: (1) restricting-type anorexia, (2) bulimic-type
anorexia, and (3) bulimia in individuals of normal weight
 Identity Formation: Parent-Child
Interaction
• One of the earliest approaches to the self-concept in eating disorders
focuses on the process of identity formation in childhood and
adolescence (looking at the dynamics of the parent-child relationship)
• Highly controlling and perfectionistic parents limit the child's
opportunities for autonomous functioning by responding to her based on
their expectations for perfection rather than to the child's expressed
needs and desires.
• Within this environment, the child fails to develop a sense of herself as an
autonomous, volitional agent but rather relies on her parents as her
source of self-definition.
• As the child encounters the challenges associated with adolescence, this
lack of self-definition gives rise to overwhelming feelings of
incompetence, self-doubt, and fears of losing control. Within this
framework, the weight-loss and food-restricting behaviors are a
maladaptive way of defining the self and establishing a sense of self-
control
Cultural Ideals and Concept of the Self
• The cultural ideal of women as dependent, accommodating, and
beautiful, or conflict generated by the competing visions of the
ideal woman as both bright, competent, accomplished, pleasing,
compliant, and unassertive become the organizing framework for
one's self-definition and impede the processes of self-exploration
and discovery.

• Common across these various theoretical approaches is the view

that the preoccupation with body weight and the disordered eating
behavior are a maladaptive attempt to compensate for a
disordered concept of the self---one that is immature,
impoverished, and incomplete.
• Although this conceptualization of the self-concept in eating
disorders is widely accepted within the medical literature, little
empirically based knowledge is available to support the claim.
 Body Image Distortions
• Disordered eating behaviors of anorexia and bulimia stem from the
subjective experience of one's body--either overall or specific parts-
-as larger or fatter than it objectively is.
• For both disorders, body size overestimation is thought to be a
indicator of poor outcome.
• Some argue that the body size overestimation is an indicator of
underlying perceptual processing abnormalities.
• This perspective is founded on the theory that women with
anorexia are unable to accurately perceive internal sensations.
• It is believed to stem from the lack of synchrony in the parental-
child relationship and is thought to lead to the inability to
accurately perceive physiological signals such as hunger and satiety,
emotional states such as anger and sadness, and information about
one's body boundaries and shape.
 Body Image Distortions
• Others suggest that the individual's mental representation of her body is
simply inaccurate and too large due to changes in one's body and
problems with the way they measure body size and shape.
– Their body image was formed during a period when the individual was heavier
and the representation failed to accommodate to the thinner body size.

• Body-size overestimation and the accompanying subjective feelings of

fatness do not reliably distinguish women with eating disorders from
others, including women without eating disorder symptoms, pregnant
women, obese women, and those who engage in subclinical levels of
disordered eating behaviors.
• The pervasiveness of body-size overestimation in populations of women
without eating disorders raises important questions about how body-
image disturbance causes severe dysfunctional behaviors in only some
women.
 Self-Esteem Disturbances
• Another type of self-concept deviation that has been linked to anorexia and bulimia is a
disturbance in attitudes toward the self, in the areas of body satisfaction and global self-
esteem.
• Body satisfaction generally refers to the level of positive versus negative feelings towards the
physical self
• Body satisfaction can range from statements about how much one likes specific parts of the
body (i.e., hips, bust, or face) to the overall physical self, evaluations of one's body size
(either specific parts or overall body); or the degree of discrepancy between one's perceived
size and desired size.
• Global self-esteem is defined as the level of satisfaction with one's overall self

• Women with an eating disorder evaluate their bodies more negatively than women without
eating disorders
• In addition, they report lower global self-esteem than women without disorders
• However, other populations of women have also been found to have high levels of body
dissatisfaction and low self-esteem
• These findings, along with those of studies that suggest that low self-esteem is also
associated with other psychiatric illness that are prevalent in women such as depression,
suggest that negative attitudes towards the self is not a characteristic solely related to eating
disorders.
Schema model of the Self-Concept
• The schema model of the self-concept is based on the
assumption that behavioral responses to stimuli are
mediated through an internal system of knowledge
structures sometimes referred to as schemas
• Schemas are organizations of knowledge that are
constructed through interaction with the environment and
reflect the person's impression of an object or event.
• Once schemas are formed, they are stored in long-term
memory and act as the foundation for the processing of
subsequent interactions with the environment.
• To process the self-relevant stimuli routinely encountered
in day to day life, people construct knowledge structures
about the self, referred to as self-schemas.
 Self-Schemas
• Self-schemas are stable and enduring memory structures about the self that
integrate and summarize a person's thoughts, feelings and experiences about the
self in a specific behavioral domain.
• They can be formed around any aspect of the person, including physical
characteristics, social roles, personality traits, skills, competencies, and interests.

• Self-schemas include not only declarative knowledge about what the self "is" but
also procedural rules, strategies, and routines that direct and regulate behavior in
the domain.
• Self-schemas are the cognitive framework through which social stimuli are
perceived, interpreted, and recalled.

• Furthermore, because self-schemas include procedural knowledge, the person

with a self-schema has a repertoire of behaviors available that enables efficient,
competent, and consistent functioning
• It is these functional properties of the self-schemas that link them to behavior.
 Self-Concept
• The self-concept refers to the person's total collection of cognitions about
the self that are articulated in memory including the self-schemas and
other less fully elaborated images of the self
• Whereas some individuals have many domains that are core or central to
their self-definition, others have relatively fewer.
• Furthermore, individual differences in the number of self-schemas
included in the self-concept have been linked to emotional and behavioral
outcomes including depression, poor self-esteem and inability to adapt
to stress
• In addition to the overall evaluation of one's worth, people also have
stable attitudes reflecting their feelings of worth in each of the behavioral
domains that comprise the self-concept
• Studies have shown that people evaluate themselves differently in each
behavioral domain that comprises the self-concept and that these
domain-specific self-evaluations serve as the foundation that gives rise to
one's overall level of self-satisfaction
 Self-Schemas
• Some cognitions may be chronically accessible in working memory
and therefore, persistently used as the framework for the
processing of stimuli.

• Individuals with an accessible schema in a domain are not only

more likely to selectively attend to aspects of a social stimulus that
are consistent with it but in addition, when a stimulus is vague, are
likely to use the accessible cognition to interpret and assign
meaning to the event

• It is suggested that a limited collection of positive self-schemas

available in memory, in combination with a chronically and
inflexibly accessible body-weight self-schema, together lead to the
onset and maintenance of the disordered behaviors associated
with anorexia and bulimia.
 Impact of Self Schemas on the View
of the Self
• An adolescent who has many positive self-schemas available in memory will have a
clearer and more stable view of the self and a broader repertoire of behavioral
strategies that can be used to give form and meaning to behavior.

• In contrast, the person who has few positive self-schemas elaborated within the
self-concept will have fewer skills available to effectively cope with challenges and
will be more likely to experience feelings of confusion, frustration, and
incompetence.

• As suggested by Bruch (1973), in an attempt to relieve distress and establish a

sense of identity and self-worth, the person with few positive self-schemas may
assign unusual importance to her body weight self-conceptions.

• In some cases, the lack of a diverse array of positive self-schemas may reflect an
actual deficit in development, such that positive knowledge structures about the
self were never formed.
 Self-Schemas
• Many of the etiologic factors cited in the literature, such as the
highly controlling and restrictive parental relationship and the
cautious, perfectionist personality styles of the child, may limit
opportunities for exploration and experimentation in a variety of
social and competency-based arenas.

• Individuals who have a limited range and depth of experience will

have fewer opportunities to develop positive self-schemas.

• In other cases, positive self-schemas may have been formed earlier

in development but may become disorganized and dysfunctional in
response to a stressful life event. In these cases, the constrained
array of positive self-schemas does not reflect a developmental
deficit but rather an acute cognitive response to a stressor.
• “Collapse of the person's world view": Certain life events, such as divorce or
separation from parents, may be so disruptive to the person's core self-conception
that the total self-definition is threatened. During such periods of destabilization of
the self-system, existing self-schemas may become fragmented and disorganized,
and functionally, the individual may not have accessible the network of self-
relevant expertise.
• Among the important features of the self-concept that may distinguish women
with an eating disorder from other women with identity disturbances and low self-
esteem may be the availability of a body-weight self-schema
• The body-weight schema has been defined as a collection of cognitive and
affective (emotional) representations that focuses on one's body shape and size
• It is constructed within the social environment and reflects evaluations and
categorizations made by oneself and others. The bodyweight schema is thought
to include not only semantic knowledge but also proprioceptive and imaginal
information as well.
 Proprioceptive and Procedural
Knowledge
• The emaciated anorexic woman who complains of
feeling fat and rates herself as larger than she
objectively is, may be articulating proprioceptive
information encoded within the self-schema at a point
when she was objectively heavier, which is now re-
experienced each time the body-weight self-schema is
activated in working memory.
• Similarly, the bingeing, purging, and other ritualistic
eating and exercise behaviors can be viewed as the
procedural knowledge that is stored within the self-
schema and enacted each time the schema is
activated.
 Accessibility of the Overweight Self-
Schema
• Studies have shown that self-schemas are automatically activated and exert a powerful
influence over the processing of self-relevant information
• A woman with an overweight schema who has few other self-schemas accessible is likely to
use the overweight schema as the interpretative framework for a broader array of self-
relevant stimuli

• During periods of cognitive fatigue, active processing functions may be diminished and her
ability to suppress activation of the overweight self-schema severely reduced.
• This formulation of diminished active processing and resultant chronic accessibility of the
bodyweight schema is consistent with findings that suggest that the onset of eating disorder
behaviors is often associated with a major precipitating event
• A major life event is likely to be associated with many attention-demanding stimuli, which
can lead to mental fatigue and a diminished ability to suppress the already highly accessible
overweight self-schema

• Within this framework, the self-schemas may be considered the critical mediating variables
for explaining how aspects of the immediate interpersonal and broader sociocultural
environments---either in the form of cultural standards for female beauty, persistent teasing
by peers, or controlling, perfectionistic parental standards- impact processes of self-
regulation and behavior
 Interventions
• Currently, interventions on the self-concept in eating disorders focus on
changing faulty beliefs about one's body weight and shape
• Interventions may also focus on modifying the self-concept’s chronic
accessibility. Interpersonal interactions that focus on food and body
weight might be discouraged, and even treatment strategies such as food
diaries and meal planning could be re-evaluated for their effects on the
accessibility of body-weight schema.

• Building on the view that women with an eating disorder lack a clear self-
definition and therefore a source of positive self-esteem, an important
focus of therapy may be on the construction of new self-schemas.
• Rather than striving to change existing negative cognitions about one's
body weight, interventions aimed at identifying unacknowledged
personal strengths and elaborating them into valued sources of self-
definition may be an important strategy for diminishing the accessibility of
the body-weight self-definition and improving confidence and self-esteem.
 Causes of Eating Disorders: Clients’
Opinions
• Despite a substantial body of research, there is
still no consensus among researchers and
clinicians on the etiology (cause) of anorexia.
• Risk factors for the illness fall into the
sociocultural, family, and individual domains.
• Social-cultural theories focus on the widespread
pressure on young girls in Western societies to be
thin (The cultural pressures may be necessary
conditions for the development of eating
disorders, but they are clearly not sufficient.)
 Causes of Eating Disorders
• Dieting behavior may be the most well-established risk factor for the development
of anorexia.
• In their longitudinal study, Patton, Selzer, Coffey, Carlin, and Wolfe (1999) indicated
that severity of dieting is the most important predictor of the development of an
eating disorder in adolescent girls. Earlier age of dieting is also associated with
increased risk.
• A family history of anorexia or other weight issues and other psychiatric disorders
such as depression and anxiety disorders are more common in the family
members of women with anorexia.
• Specific patterns of family interaction have been observed such as rigidity,
overprotectiveness, excessive control, and marital discord.
• However, there is no evidence of a ‘‘typical’’ anorexia family.

• Individual temperament and personality features such as harm avoidance,

obsessionality, perfectionism, and low self-esteem are also traits that increase the
risk of developing anorexia.
• Several authors have shown that psychological stress or stressful life events can
trigger the onset of anorexia.
 Causes and Recovery of Eating
Disorders: Clients’ Opinions
• People with a past history of anorexia, even if recovered, retain
characteristics such as perfectionism, cognitive restraint, and a
preoccupation with symmetry and exactness. They continue to
maintain a body mass index that is below the norm.
• More than 1/3 of clients highlighted family dysfunction as a
contributing factor to the development of their eating disorder:
(poor parental care/childhood deprivation, parental overcontrol,
poor relationship with parents, pervasive family tension/fights,
and emotional abuse).
• The next most commonly perceived causes were weight
loss/dieting and stress and frustration.
• The categories perceived to be associated with recovery and the
percentage of individuals who cited them as important to their own
recovery. The three most commonly mentioned factors were a
supportive relationship, growing out of the disorder, and therapy.
 Other Potential Causes
• There does not appear to be a unique family interaction pattern
that is characteristic of anorexic people
• Overprotectiveness has been implicated as a cause of the disorder
and may occur before the onset of the illness.
• Many people with anorexia attribute the etiology of their disorder
to factors associated with dysfunction in the family.
• For more than 20% of the clients, a diet or the intention to lose
weight preceded the onset of the disorder. Most of them described
a loss of control of the dieting behavior.
• About 20% of patients cited some form of stress as causal in their
eating disorder.
• Anorexic individuals commonly report histories of childhood
anxiety.
 Causes (Clients’ Perspective)
• Families of individuals with bulimic behavior are more
conflictual and less cohesive.
• There are greater reports of family dysfunction (as well as
child sexual abuse) among people with anorexia of the
bulimic subtype.
• People with a poor outcome more frequently reported a
history of childhood sexual abuse, a family with weight
and food concerns, and lower self-esteem.
• Participants said that a supportive relationship was the
driving force that assisted them in recovery.
• Many of them also said they matured out of the disorder.