Editor’s Note:

Welcome to the thirty-ninth edition of the NEDC e-Bulletin. Research shows that specific genetic, psychological and socio-cultural factors can increase one’s likeliness of developing an eating disorder. This edition we review existing evidence on eating disorders risk factors and seek expert advice on perfectionism. We also answer our first public question on bullying and eating disorders!

The NEDC are pleased to release the next resource in our series of specialised information packages for health professionals: Pharmacy and Eating Disorders. A pharmacist is often the first health professional that a person with an eating disorder will come in contact with.This resource aims to assist Pharmacists with the early idenfitication of eating disorders. To read more and download this resource, follow the article link below.

If you are interested in collaborating with the NEDC, we encourage you to join and become an NEDC member.

Contents:

1. Evidence Review: Risk Factors for Eating Disorders 
2. Expert Advice: Prof. Tracey Wade on Perfectionism and Eating Disorders
3. Q and A: Can Bullying Cause Eating Disorders?
4. New Resource: Pharmacy and Eating Disorders

Eating disorders are complex mental illnesses. To date, no single cause has been identified. Rather, widespread research suggests that the onset of an eating disorder is unique to the individual and often involves the integration of multiple factors (Culbert, Racine, & Klump, 2015; Rikani et al., 2013). Understanding these known risk factors has the potential to improve treatment methods, determine high risk groups for prevention programs and reduce stigma (Striegel-moore & Bulik, 2007). Current literature explores genetic, psychological and socio-cultural influences.

Genetic Vulnerability

The genetic link to eating disorders has been a consistent focus in scientific literature. Previous findings from family and twin studies indicate that eating disorders have a hereditary component (Trace, Baker, Pe, & Bulik, 2013). In particular, one study found that first-degree relatives of individuals with Anorexia Nervosa are 11 times more likely to develop the illness than relatives of individuals without the disorder (Strober, Freeman, Lampert, Diamond, & Kaye, 2000). This suggests that genetics can influence an individual’s vulnerability to eating disorders.

The onset of eating disorders, specifically Anorexia Nervosa and Bulimia Nervosa, typically occurs during adolescence (Hudson, Hiripi, Pope, & Kessler, 2007; Striegel-moore & Bulik, 2007). The complex hormonal, physical and neural changes associated with puberty increase the likelihood of adolescent engagement in disordered eating behaviours (Klump, 2013). Given such, puberty is recognised as a significant risk period.

Although there has been decades of research exploring the genetics of eating disorders, the biological causes are still not well understood. This may be because the majority of studies involve small sample sizes and are often conducted during the acute or recovery phase of an eating disorder (Trace et al., 2013). The QIMR Berghofer Medical Research Institute in Queensland are currently undertaking the largest international investigation into the cause of Anorexia Nervosa. This study, known as the Anorexia Nervosa Genetic Initiative (ANGI), seeks to identify the specific genes associated with Anorexia Nervosa in the hopes of better understanding the causes and finding a potential cure.

Psychological Factors

A connection between certain personality traits and eating disorders has been identified. Research into Anorexia Nervosa and Bulimia Nervosa has shown that obsessive compulsive personality disorder, low self -esteem and perfectionism are considerable risk factors for disordered eating behaviours and attitudes (Culbert et al., 2015; Egan, Wade, & Shafran, 2011). A recent investigation into childhood obsessive compulsive personality traits found that the presence of perfectionism and inflexibility in early life can predict the later development of an eating disorder (Southgate, Tchanturia, Collier & Treasure, 2008). Personality types are also important to consider when treating an eating disorder, as obsessive compulsive tendencies may continue to drive restrictive and rigid behaviours. Given such, Egan et al. (2011) argues that traits such as perfectionism should be treated alongside an eating disorder, in order to effectively reduce disordered eating symptoms.

The cognitive, behavioural and interpersonal changes that accompany eating disorders can make it difficult to discern the psychological causes from the psychological effects. For example, the co-existence of depression and anxiety with eating disorders has raised debate as to whether such conditions precede or are a direct outcome of an eating disorder.

Socio-Cultural Influences

Socio-cultural influences play a considerable role in the development of eating disorders. Mass media, such as television, magazines and advertising, airbrush and alter images to portray unrealistic representations of the male and female body (Perloff, 2014; Striegel-moore & Bulik, 2007). Predominant images suggest that beauty is associated with thinness for females and a lean, muscular body for males. Individuals who internalise this ‘thin’ ideal and strive for the ‘perfect’ body, are at a greater risk of developing body dissatisfaction, which can lead to dieting and other disordered eating behaviours (Culbert et al., 2015). More recent research has explored the impact of social media on body image and eating behaviours. Andsager (2014) argues that the introduction of Facebook and Instagram has increased our exposure to photo-shopped images and thin ideals. Although a direct link to eating behaviours is yet to be established, the appearance-focused nature of social media platforms has been shown to cultivate body image concerns and reduce self-esteem (Perloff, 2014).

Additionally, there is growing evidence that the ways in which weight, shape and size are discussed in the home have a strong impact on self-esteem and dieting behaviours (Loth et al., 2014). Culbert et al. (2015) propose that environmental and psychological factors interact with and influence the expression of genes to cause eating disorders. Further research into this relationship is needed.

Modifiable Risk Factors

Identifying potential risk factors for eating disorders is beneficial in shaping effective prevention and early intervention programs. Research indicates that prevention programs with the most favourable outcomes are those which focus on reducing modifiable risk factors (Jacobi, Hayward, Zwaan, Kraemer, & Agras, 2004). Low self-esteem, body dissatisfaction, dieting behaviours and internalisation of the thin ideal have been acknowledged as variable factors associated with the onset of eating disorders.

The aetiology of eating disorders is becoming a growing field of research. Although limited conclusive evidence has been recorded, understanding possible influences can inform best practice and encourage effective management of eating disorders.

References

Andsager, J. L. (2014). Research Directions in Social Media and Body Image. Sex Roles, 71, 407–413.

Culbert, K. M., Racine, S. E., & Klump, K. L. (2015). Research Review : What we have learned about the causes of eating disorders – a synthesis of sociocultural , psychological , and biological research. Journal of Child Psychology and Psychiatry, 11, 1141–1164.

Egan, S. J., Wade, T. D., & Shafran, R. (2011). Perfectionism as a transdiagnostic process : A clinical review. Clinical Psychology Review, 31(2), 203–212.

Hudson, J. I., Hiripi, E., Pope, H. G., & Kessler, R. C. (2007). The Prevalence and Correlates of Eating Disorders in the National Comorbidity Survey Replication. Journal of Biological Psychiatry, 61, 348–358.

Jacobi, C., Hayward, C., Zwaan, M. De, Kraemer, H. C., & Agras, W. S. (2004). Coming to Terms With Risk Factors for Eating Disorders : Application of Risk Terminology and Suggestions for a General Taxonomy. Psychological Bulletin, 130(1), 19–65.

Klump, K. L. (2013). Puberty as a critical risk period for eating disorders : A review of human and animal studies. Hormones and Behavior, 64(2), 399–410.

Loth, K. A., Ph, D., D, R., Maclehose, R., Ph, D., Bucchianeri, M., … D, R. (2014). Predictors of Dieting and Disordered Eating Behaviors From Adolescence to Young Adulthood. Journal of Adolescent Health, 55(5), 705–712.

Perloff, R. M. (2014). Social Media Effects on Young Women ’ s Body Image Concerns : Theoretical Perspectives and an Agenda for Research, 363–377.

Rikani, A. A., Choudhry, Z., Choudhry, A. M., Ikram, H., Asghar, M. W., Kajal, D., … Mobassarah, N. J. (2013). A critique of the literature on etiology of eating disorders. Annals of Neurosciences, 20(4), 157–161.

Southgate, L., Tchanturia, K., Collier, D., & Treasure, J. (2008). The development of the childhood retrospective perfectionism questionnaire (CHIRP) in an eating disorder sample. European Eating Disorders Review, 16(6), 451-462.

Striegel-moore, R. H., & Bulik, C. M. (2007). Risk Factors for Eating Disorders. American Psychologist, 62(3), 181–198.

Strober, M., Freeman, R., Lampert, C., Diamond, J., & Kaye, W. (2000). Controlled family study of anorexia nervosa and bulimia nervosa: Evidence of shared liability and transmission of partial syndromes. The American Journal of Psychiatry, 157(3), 393–401.

Trace, S. E., Baker, J. H., Pe, E., & Bulik, C. M. (2013). The Genetics of Eating Disorders. Annual Review of Clinical Psychology, 9, 589–620.

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Professor Tracey Wade, from the School of Psychology at Flinders University, explains the link between perfectionism and eating disorders. Tracey has worked as a clinician in the area of eating disorders for over 20 years and has co-written two books on perfectionism. Her current research interests are the aetiology, prevention and treatment of eating disorders.

Based on cross-sectional, experimental and longitudinal research, perfectionism is indicated as a causal risk factor for eating disorder psychopathology. In the clinic room perfectionism can be marked by self-criticism, all or nothing thinking, fear of making mistakes and harm avoidant behaviours, and a focus on concrete rules with low tolerance for ambiguity.

A more modern example of the co-occurrence of perfectionism and eating disorders comes from Jenni Schaefer, author of “Goodbye Ed, Hello me; Recover from your eating disorder and fall in love with life”:

“In the past, my brain could only compute perfection or failure—nothing in between. So words like competent, acceptable, satisfactory, and good enough fell into the failure category.”

In terms of the specific relationship between perfectionism and eating, Schmidt and Treasure (2006) suggest:

“Individuals with these traits value perfection and fear making mistakes. They are excessively conscientious and cognitively rigid … The traits (being rigidly rule-bound, striving for perfection) can facilitate persistent dietary restriction and the control of appetite. A wish for simplicity and focus on details make this type of behaviour satisfying and may lead to the … belief ‘anorexia nervosa makes me feel in control’” (p. 349).

There is a large body of literature showing that perfectionism is malleable and is therefore a potential target for interventions with eating disorders. There is also some evidence which suggests tackling perfectionism can improve outcomes for eating disorders but more research is needed in this area.

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Bullying is a growing problem in Australia, affecting people of all ages. Bullying has been associated with several mental health issues, including depression, anxiety and more recently, eating disorders. Although there is limited investigation into the direct impacts of bullying on eating behaviours, research shows bullying can contribute to low self-esteem and body image concerns (Haines, Hannan, Berg, & Eisenberg, 2013; Unikel, A, Cm, & Ocampo, 2012). As body dissatisfaction and low self-esteem are recognised risk factors for eating disorders, it is possible that disordered eating may result.

Weight-related teasing is a major concern within school, home and work environments. A study involving university students aged between 18 to 24 years found that the most common form of teasing experienced was appearance-related, such as negative comments about weight, facial characteristics and clothing (Bhutani, Sudhir, & Philip, 2014). Unikel et al. (2012) propose that criticism related to weight and appearance can increase body dissatisfaction and contribute to dieting behaviours. An additional study found that engaging in ‘fat’ talk, for example conversations about weight, diet, exercise and others’ appearances, can result in people feeling bad about their own appearance and shape (Sharpe, Naumann, & Treasure, 2013).

Unfortunately, the introduction of social media has broadened the scope of bullying, with approximately 450,000 young Australians experiencing cyberbullying in 2013 (Katz et al., 2014). Taking the above into consideration, school, family and workplace education on appearance-related teasing is pivotal in reducing the occurrence of bullying and its subsequent impacts (Bhutani et al., 2014). Establishing positive and supportive environments may prevent the onset of low self-esteem and body dissatisfaction.

7 Tips for Improving Body Image

The NEDC have developed an infographic to encourage positive body image. This resource provides tips on how to embrace diversity and develop a positive attitude towards oneself and others.

Suggestions for Use:

• Pin to your classroom wall
• Develop a class lesson around positive self-talk and the impacts of bullying
• Pin to your staffroom wall to discourage workplace bullying
• Pin to gym noticeboards to encourage a supportive environment
  

Have a question you want answered? Here’s how it works:

1. At the beginning of every month we post a theme for our monthly e-Bulletin on Facebook
2. Facebook Message the NEDC with your related question
3. Our team will select one question and provide an evidence-based answer in the month’s e-Bulletin

Follow us on Facebook to keep up to date.

Please note, the answers provided in Q and A are based on current research findings. They are not conclusive answers.

References

Bhutani, R., Sudhir, P. M., & Philip, M. (2014). Teasing Experiences , Interpersonal Sensitivity , Self-Schema and Psychological Distress in Youth : an Exploratory Study, 59(September), 241–251.

Haines, J., Hannan, P. J., Berg, P. Van Den, & Eisenberg, M. E. (2013). Weight-Related Teasing from Adolescence to Young Adulthood : Longitudinal and Secular Trends between 1999 and 2010, 21(9), 428–434.

Katz, I., Keeley, M., Spears, B., Taddeo, C., Swirski, T., & Bates, S. (2014). Research on youth exposure to , and management of, cyberbullying incidents in Australia: Synthesis report (SPRC Report 16/2014). Sydney.

Sharpe, H., Naumann, U., & Treasure, J. (2013). Is Fat Talking a Causal Risk Factor for Body Dissatisfaction ? A Systematic Review and Meta-Analysis, 643–652.

Unikel, C., A, V. H., Cm, B., & Ocampo, R. (2012). Disordered Eating and Suicidal Intent : The Role of Thin Ideal Internalisation , Shame and Family Criticism, 20, 39–48.

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The NEDC are excited to launch Pharmacy and Eating Disorders, a new professional resource developed for Pharmacists, to support their role in the early identification of eating disorders.

A Pharmacist is often the first health professional that a person with an eating disorder will come in contact with. Given such, Pharmacists are in a key position to detect the presence of an eating disorder, encourage help seeking and assist  patients with referrals.

Research shows that substance misuse is common among people with eating disorders. This may include the use of diet pills, laxatives or other medications in order to lose weight. Pharmacists can play a vital role in the detection of eating disorders by monitoring the use of prescription and non-prescription medications and products.

A Pharmacist’s role is not to treat an eating disorder, but to encourage the patient to seek treatment. Creating a safe and comfortable environment for the patient is important in prompting disclosure and discussing next steps with them.

This resource includes key information on the signs and symptoms of eating disorders, medication misuse, drug interactions and patient referral.