Handbook of Eating Disorders - part 4 docx

134 ROZ SHAFRAN AND PADMAL DE SILVA for all forms of clinical eating disorder (Fairburn et al., in press). Finally, the cognitive- behavioural mechanisms in the maintenance of obesity are ill-understood and, at present, the long-term outcome of cognitive-behavioural therapy for this disorder is poor. It is hoped that the new theoretical developments, particularly the focus on mechanisms contributing to weight regain after successful weight loss (Cooper & Fairburn, in press-a), will improve our understanding of these mechanisms and, consequently, the treatment of obesity. ACKNOWLEDGEMENTS RS is supported by a Wellcome Trust Research Career Development Fellowship (063209). REFERENCES Agras, W.S., Walsh, T., Fairburn, C.G., Wilson, G.T. & Kraemer, H.C. (2000) A multicenter compari- son of cognitive-behavioral therapy and interpersonal psychotherapy for bulimia nervosa. Archives of General Psychiatry, 57, 459–466. Allyon, T., Haughton, E. & Osmond, H.P. (1964) Chronic anorexia: A behaviour problem. Canadian Psychiatric Association Journal, 9, 147–157. APA (1994) Diagnostic and Statistical Manual of Mental Disorders (4th edition). Washington, D.C.: American Psychiatric Association. Bachrach, A.J., Erwin, W.J. & Mohr, J.P. (1965) The control of eating behavior in an anorexic by operant conditioning techniques. In L.P. Ullman & L. Krasner (Eds), Case Studies in Behavior Modification. New York: Holt, Rinehart & Winston. Baker, J.D., Williamson, D.A. & Sylve, C. (1995) Body image disturbance, memory bias and body- dysphoria: Effects of negative mood induction. Behavior Therapy, 26, 747–759. Beck, A.T. (1976) Cognitive Therapy and the Emotional Disorders. New York: International Univer- sities Press. Beck, J.S. (1995). Cognitive Therapy: Basics and Beyond. New York: Guilford Press. Ben-Tovim, D.I., Walker, M.K., Fok, D. & Yap, E. (1989) An adaptation of the Stroop test for mea- suring shape and food concerns in eating disorders. A quantitative measure of psychopathology? International Journal of Eating Disorders, 6, 681–687. Beumont, P.J.V., George, G.C.W. & Smart, D.E. (1976) ‘Dieters’ and ‘vomiters and purgers’ in anorexia nervosa. Psychological Medicine, 6, 617–622. Blinder, B.J., Freeman, D.M. & Stunkard, A.J. (1970) Behavior therapy of anorexia nervosa: Effec- tiveness of activity as a reinforcer of weight gain. American Journal of Psychiatry, 126, 1093–1098. Braun, D.L., Sunday, S.R. & Halmi, K.A. (1994) Psychiatric comorbidity in patients with eating disorders. Psychological Medicine, 24, 859–867. Bray, G.A., Bouchard, C. & James, W.P.T. (1998) Handbook of Obesity. New York: Marcel Dekker. Brewin, C. (1988) Cognitive Foundations of Clinical Psychology. Hove, UK: Lawrence Erlbaum. Bruch, H. (1973) Eating Disorders. New York: Basic Books. Bruch, H. (1982) Anorexia nervosa: Therapy and theory. American Journal of Psychiatry, 139, 1531– 1538. Bulik, C.M., Sullivan, P.F., Joyce, P.R. & Carter, F.A. 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Fairburn (Eds), Science and Practice of Cognitive Behaviour Therapy. Oxford Medical Publications. Oxford: Oxford University Press. Cooper, M.J. (1997) Cognitive theory in anorexia nervosa and bulimia nervosa: A review. Behavioural and Cognitive Psychotherapy, 25, 113–145. Cooper, M., Cohen-Tovee, E., Todd, G., Wells, A. & Tovee, M. (1997) The eating disorder belief questionnaire: Preliminary development. Behaviour Research and Therapy, 35, 381–388. Cooper, M. & Fairburn, C.G. (1992a) Selective processing of eating, weight and shape related words in patients with eating disorders and dieters. British Journal of Clinical Psychology, 31, 363–365. Cooper, M. & Fairburn, C.G. (1992b) Thoughts about eating, weight and shape in anorexia nervosa and bulimia nervosa. Behaviour Research and Therapy, 30, 501–511. Cooper, M. & Turner, H. (2000) Underlying assumptions and core beliefs in anorexia nervosa and dieting. British Journal of Clinical Psychology, 39, 215–218 Cooper, Z., & Fairburn, C.G. 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Fairburn (Eds), Science and Prac- tice of Cognitive Behaviour Therapy. Oxford Medical Publications. Oxford: Oxford University Press. Fairburn, C.G. & Brownell, K.D. (Eds) (2002) Eating Disorders and Obesity: A Comprehensive Handbook (2nd edn). New York: Guilford Press. Fairburn, C.G., Cooper, Z., Doll, H.A. & Welch, S.L. (1999) Risk factors for anorexia nervosa: Three integrated case control comparisons. Archives of General Psychiatry, 56, 468–476. Fairburn, C.G., Cooper, Z. & Shafran, R. (in press) Cognitive-behaviour therapy for eating disorders: a ‘transdiagnostic’ theory and treatment. Behaviour Research and Therapy. Fairburn, C.G., Marcus, M.D. & Wilson, G.T. (1993) Cognitive-behavioral therapy for binge eating and bulimia nervosa: A comprehensive treatment manual. In C.G. Fairburn, G. Christopher & G.T. Wilson (Eds), Binge Eating: Nature, Assessment, and Treatment. New York: Guilford Press. Fairburn, C.G., Norman, P.A., Welch, S.L., O’Connor, M.E., Doll, H.A. & Peveler, R.C. 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(1995) Selective information processing of body size and food related stimuli in women who are preoccupied with body size. Advances in Health Care Research, 14, 61–66. Garfinkel, P.E. & Garner, D.M. (1983) Anorexia Nervosa: A Multi-dimensional Perspective. New York: Brunner/Mazel. 136 ROZ SHAFRAN AND PADMAL DE SILVA Garner, D.M. & Garfinkel, P.E. (Eds), Handbook of Treatment for Eating Disorders (2nd edn). New York: Guilford Press. Garner, D.M. & Bemis, K.M. (1982) A cognitive-behavioral approach to anorexia nervosa. Cognitive Therapy and Research, 6, 123–150. Garner, D.M. & Bemis, K.M. (1985) Cognitive therapy for anorexia nervosa. In D.M. Garner & P.E. Garfinkel (Eds), Handbook of Psychotherapy for Anorexia Nervosa and Bulimia. New York: Guilford Press. Garner, D.M., Vitousek, K.M. & Pike, K.M. (1997) Cognitive-behavioral therapy for anorexia nervosa. In D.M. Garner & P.E. Garfinkel (Eds), Handbook of Treatment for Eating Disorders (2nd edn). New York: Guilford Press. Gelder, M. 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(1998) A cognitive model and treatment strategies for anorexia nervosa. In H.W. Hoek, J.L. Treasure & M.A. Katzman (Eds), Neurobiology in the Treatment of Eating Disorders. Wiley series on Clinical and Neurobiological Advances in Psychiatry. Chichester John Wiley & Sons. Wolpe, J. (1958) Psychotherapy by Reciprocal Inhibition. Stanford: Stanford University Press. Wolpe, J. (1993) The cognitivist oversell and comments on symposium contributions. Journal of Behavior Therapy Experimental Psychiatry, 24, 141–147. Wooley, S.C., Wooley, O.W. & Dyrenforth, S.R. (1979) Theoretical, practical and social issues in behavioral treatment of obesity. Journal of Applied Behavior Analysis, 12, 3–25. CHAPTER 8 Sociocultural Theories of Eating Disorders: An Evolution in Thought Mervat Nasser Department of Psychiatry, Thomas Guy House, London, UK and Melanie Katzman 29 West, 88th Street, New York, USA In this chapter we trace the evolution of cultural explanations for disordered eating. Beginning with the individual’s interface with the environment and traditional psycho- dynamic forces, we work through gender-focused and western-oriented explanations until we conclude with global changes, the role of technology and even some theorising about prevention. Table 8.1 at the end of this chapter provides a visual map of this journey. EATING PATHOLOGY: THE INTERFACE BETWEEN THE INDIVIDUAL AND THE ENVIRONMENT Self-starvation: The Psychological Predicament The embodiment of the psyche in human form and the dialectic of this body with its envi- ronment has been central to all causal theories of eating disorders long before the study of sociocultural influences became the vogue. In fact early psychodynamic descriptions of the anorexic syndrome did not ignore the importance of placing the phenomenon within the con- text of the individual’s environment. Initially psychodynamic attention was understandably focused on the contribution of the dysfunctional family as a microcosmic environment. As early as the 1800s authors remarked upon the importance of ‘placing in parallel the morbid condition of the patient and the preoccupation of those who surround her. The moral medium amid which the patient lives, exercises and influences would be regrettable to overlook or misunderstand’ (Las´egue, 1873). Handbook of Eating Disorders. Edited by J. Treasure, U. Schmidt and E. van Furth. C  2003 John Wiley & Sons, Ltd. 140 MERVAT NASSER AND MELANIE KATZMAN Table 8.1 Eating disorders: The sociocultural model 1873–1971 Non-specific neurosis Environmentally responsive 1970s Specific neurosis Ego/family dynamics 1980s Culture-specific neurosis Western culture dynamics Symbolic morbidity: Reflects notions of thinness promoted by culture Continuum morbidity: Subclinical forms merging with normality Cultural epidemiological evidence/(? increase over 50 years) Cross-cultural evidence/(? absent/rare in non-western cultures) 1990s Gender specific Gender dynamics: Metaphorical manipulation of the body The New Millennium Worldwide neurosis Worldwide culture dynamics ‘Cultures in transition’/confused identities in the flesh From a psychoanalytic perspective, the anorexic disorder was considered an unusual variation on the neurotic theme and its historical relationship to hysteria is well established in the literature (see Silverstein & Perlick, 1995). Anorexia nervosa remained fairly incon- spicuous and only gained prominence in the past 30 years when it moved from being a ‘mere’ manifestation of neurosis to a specific neurotic syndrome in its own right (Russell, 1970). Self-starvation: Specific Neurosis Reactive to the Cult of Thinness The specific diagnostic status acquired by anorexia nervosa has been attributed to a raise in incidence, an increase that is debatably one of perception, detection, or real presentation change. However, several publications have documented an increase over the past 50 years in western nations (Lucas et al., 1991; Hoek, 1993). This apparent rise was curiously noted to take place against a background of declining hysteria. This was interpreted as an indication of a change in social preoccupations which consequently changed our perception and definition of what we regard as ‘morbid’. Both hysteria and anorexia nervosa were seen as representing ‘adaptive processes’ in the face of particular environmental factors. Hysteria was commonly thought to be the product of a sex- ually repressive environment while the anorexic thinness began to be viewed as responding to new environmental demands that promoted the desirability of thinness (Swartz, 1985). The cultural shift towards a ‘thin ideal’ was noted in art, fashion and media advertisements and seemed to have been easily endorsed by women, the common sufferers of the disorder. The pursuit of thinness had metaphorical connotations, which meant alotmorethan thinness, such as a pursuit of beauty, attractiveness, health and achievement (Garner & Garfinkel, 1980; Scwarz et al., 1983; Anderson & Di Domenico, 1992). SOCIOCULTURAL THEORIES OF EATING DISORDERS 141 Self-starvation and Eating Disorders: The Continuum Hypothesis The growing obsession with thinness was then considered responsible for the pervasive dieting behaviour, which in turn was linked closely to the full anorexic syndrome. This experience, said Crisp (1981), ‘is wide spread amongst the female adolescent population and although it becomes very intense in the anorectic to be, it would not appear to be qualitatively different at this stage from the more universal experience’. The observation that the morbid phenomenon of extreme thinness does in fact blur and merge with what is considered to be normal or culturally acceptable, such as the practice of dieting, formed the basis of the continuum hypothesis. In other words, dieting falls at one end of the spectrum and the extreme forms of disordered eating at the other end with a number of weight-reducing behaviours of variable intensities in between. The ‘continuum’ theory of severity was confirmed in a number of community studies which showed the presence of subclinical forms in normal student populations (Button & Whitehouse, 1981; Clarke & Palmer, 1983, Szmukler, 1983; Mann et al., 1983; Johnson- Sabine et al., 1988; Katzman et al., 1984). In fact the subclinical forms were generally esti- mated to be five times more common than the full-blown syndromes (Dancyger & Garfinkel, 1995). The epidemiological impression that bulimia and bulimic behaviours appear to be far more prevalent in the community than the anorexic syndrome raised the possibility that the nature of both conditions, despite psychopathological similarities, are different. In the case of anorexia, the cardinal feature is restraint, which requires a strong internal drive; however, the bulimic disorder may be more responsive to external environmental reinforces (Palmer, 1999). It was even suggested that bulimia could be the result from a set of ‘socially contagious’ behaviours (Chiodo & Latimer, 1983). Hoek et al. (1995) in their cross-cultural work in Cura¸cao have suggested that anorexia may be more epidemiologically stable while bulimia may increase with growing urbaniza- tion. (For more discussion on epidemiological issues please refer to the chapter by Hoeken, Seidell and Hoek in this volume.) Whether one looked at anorexia or bulimia over time, one thing was consistent: more women than men were demonstrating clinical and subclinical concerns with weight and diet. Why should this be an issue specific to women and why at this point in history? Eating Disorders: Gender Specific? The ‘why woman’ question in the early 1980s was framed as a feminist issue although, as writers later in the twentieth century revealed, the question of gender is one that impacts all professionals working in the field of eating disorders (Katzman & Waller, 1998). Women’s susceptibility to eating problems and the pursuit of a thin ideal has been viewed as a rebellion against the adult female form and all that is implied with being a woman in today’s society—an effort to obtain an androgynous physique at a time when men are still viewed as more powerful, as a means of demonstrating mastery and control, and of course a realistic adaptation to the availability of fashionable clothes and a susceptibility to the ‘culture of health’ in which leanness is associated with longevity. Katzman (1998) suggested that it was the female access to power that was critical in the debate and not the chromosomal make-up of eating-disordered sufferers. She suggested 142 MERVAT NASSER AND MELANIE KATZMAN that it was power not gender that mattered, and it just so happened that more women had obstacles to independence and achievement. Littlewood (1995) noted that, looking cross- culturally, it was in fact the ability for self-determination that differentiated male and female eating problems. (The gender dimension in eating disorders in males is further explored by Fichter and Krenn in Chapter 23 of this volume; also such psychological factors as the role of power, control, self-esteem and self-regulation are dealt with by Serpell and Troop in Chapter 9.) Eating Disorders: Culture Specific The expansion of the gender debate to include a study of social and political impacts on behaviour enabled the field to consider the importance not only of western cultures but of all cultures. While the early 1980s and 1990s enjoyed a fascination with the western women’s predicament, and the eastern women’s ‘protection’ from eating distress (by virtue of clearly defined social roles and acceptance of plumpness as a sign of success), further sophistication of these models revealed not only gender myopia but also a cultural visual restriction. No one was immune to eating problems. Perhaps our diagnostic criteria and theoretical lenses had been somewhat selective. Although eating disorders in the 1980s and early 1990s were considered culture bound (Prince, 1983; Swartz, 1985), by the end of the 1990s, with increasing data from the east, the limitations of seeing the problem as exclusive to ‘one culture’ and ‘one sex’, namely western culture and western women, were apparent. Eating Disorders: A Worldwide Concern—from Specific to Global Nasser (1997) conducted an extensive review of the published studies of eating disorders in the east and west and found few national or societal boundaries that contained the growing detection of eating problems, albeit sometimes with a twist. For example, in the east, the work of Sing Lee and colleagues consistently demonstrated anorexia in the absence of a fear of fat. These findings, along with discoveries of eating issues in unexpected places like the Middle East, challenge us not to ask ‘if’ problems exist but ‘how’? For example: How do they present themselves? How do we understand and treat these problems? How can we be inspired in our aetiological models by data that may challenge our traditional notions of why people choose to alter their bodies or diets in times of distress? The emergence of eating pathology in the majority of societies was initially linked to an exposure to and identification with western cultural norms in relation to weight and shape preferences—especially for women. The media was considered the main culprit in disseminating these values and in homogenising public perceptions. The pressure to ‘remake the body’ to match a newly unified global aesthetic ideals was seen to operate through international advertising and worldwide satellite networks. While certainly plausible, the questions remain of why women would be so susceptible to media programming, and what does the globalisation in the marketplace reflect in terms of women’s roles that might impact on the development of eating disorders? In an analysis of ‘feminism across cultures’, Nasser (1997) pointed to the fact that feminist movements similar to those in the west also arose in other non-western societies, which SOCIOCULTURAL THEORIES OF EATING DISORDERS 143 resulted in questioning and debating traditional gender roles. The majority of non-western women have significantly changed their position, with increasing numbers of them being highly educated and working outside the family. This meant that all women of different cultures and societies increasingly share the pressures that are hypothesised to increase western women’s propensity to eating disorders. So yet again the opening of a theoretical frontier brings with it as many questions as it does inspirations. For example, does ‘westernisation’ only mean ‘image-identification’ or is there more to it? How would the issue of westernisation relate to other issues such as urbanisation, modernisation and economic globalisation? And even if we tried to break down the concept into constituent elements, would that be sufficient to explain a universal preoccupation with weight? Or does ‘weight’ mean perhaps much more than mere body regulation? Is it a quest for refashioning the body? Is the quest for refashioning the self (i.e. remaking of a new identity) able to translate and negotiate the impact of a volatile and constantly changing culture? THE EVOLUTION OF EATING PSYCHOPATHOLOGY AS A METAPHOR FOR CONTROL Body Regulation and Identity In some of the early descriptions of the anorexic syndrome, one can find fashion-driven explanations for the role of environment in the development of eating psychopathology. Bruch (1982) indicates that the environment of the family with its pathological interac- tions could indeed create an ‘identity deficit’. Within this remit, the anorexic symptoma- tology serves as a defence against feelings of ‘powerlessness’, and the act of food refusal becomes symbolic of a strive towards autonomy and mastery over one’s self as well as others. The failure of individuality or incomplete identity described in Bruch’s analysis was later applied beyond the boundaries of the domestic circle, to include an individual struggle for autonomy against social pressures in a much wider context. The feminist text clearly put the notion of identity at centre stage within the anorexic struggle. Self-starvation is seen as allowing women a sense of power to develop an identity as a person in the absence of real control or power in other areas of their life (Orbach, 1986; Lawrence, 1984). The current status of our understanding of the conceptual aspects of eating disorders is central to an ongoing debate and a specific chapter in this volume is allocated to a discussion of this topic. The author(s) of this chapter question the validity of our current categories, raising the contention of whether eating disorders are ‘real disorders’ or mere categories that do not take into account the ‘meaning’ of these behaviours and serve only as convenient pigeon-holes. The Cultural Transition and the Social Predicament Historically the displacement of the locus of power to the body was noted to occur during periods of cultural transition, particularly at times when ‘identity definition or redefinition’ [...]... Goldner, E., Remick, R & Birmingham, L (1998) Shape- and weight-based self-esteem and the eating disorders International Journal of Eating Disorders, 24, 285–298 Geller, J., Srikameswaran, S., Cockell, S & Zaitsoff, S.L (2000) Assessment of shape- and weightbased self-esteem in adolescents International Journal of Eating Disorders, 28, 339– 345 1 64 LUCY SERPELL AND NICHOLAS TROOP Gillberg, I., Rastam,... Sheppard-Sawyer, C.L., McNally, R.J & Fischer, J.H (2000) Film-induced sadness as a trigger for disinhibited eating International Journal of Eating Disorders, 28, 215–220 166 LUCY SERPELL AND NICHOLAS TROOP Skodol, A., Oldham, J., Hyler, S., Kellman, H.D., Doidge, N & Davies, M (1993) Comorbidity of DSM-III-R eating disorders and personality disorders International Journal of Eating Disorders, 14, 40 3 41 6... crisis support in eating disorders International Journal of Eating Disorders, 24, 157–166 Troop, N.A., Holbrey, A., Trowler, R & Treasure, J.L (19 94) Ways of coping in women with eating disorders Journal of Nervous and Mental Disease, 182, 535– 540 PSYCHOLOGICAL FACTORS 167 Troop, N.A., Treasure, J.L & Serpell, L (2002) A further exploration of disgust in eating disorders European Eating Disorders Review,... study of deliberate self-harm and alcohol and drug misuse in a community sample British Journal of Psychiatry, 169 (4) , 45 1 45 8 Wiederman, M W & Pryor, T (1996) Multi-impulsivity in bulimia nervosa International Journal of Eating Disorders, 20 (4) , 359–365 Wonderlich, S.A., Swift, W J., Slotnick, H.B & Goodman, S (1990) DSM-III-R personality disorders in eating disorders subtypes International Journal of. .. Sanftner, J., Bonifazi, D.Z & Shepherd, K.L (2001) The role of daily hassles in binge eating International Journal of Eating Disorders, 29, 44 9 45 4 Davey, G.C.L., Buckland, G., Tantow, B & Dallos, R (1998) Disgust and eating disorders European Eating Disorders Review, 6, 201–211 Fahy, T & Eisler, I (1993) Impulsivity and eating disorders British Journal of Psychiatry, 162, 193–197 Fairburn, C.G., Welch, S.L.,... of developing an eating disorder International Journal of Eating Disorders, 6, 713–7 24 Lacey, J.H & Read, T (1993) Multi-impulsive bulimia: description of an inpatient eclectic treatment programme and a pilot follow-up study of its efficacy European Eating Disorders Review, 1, 22–31 Lacey, J.H (1993) Self-damaging and addictive behaviour in bulimia nervosa British Journal of Psychiatry, 163, 190–1 94. .. J.L (1997a) The role of general family environment and sexual and physical abuse in the origins of eating disorders European Eating Disorders Review, 5, 1 84 207 Schmidt, U.H., Jiwany, A & Treasure, J.L (1993b) A controlled study of alexithymia in eating disorders Comprehensive Psychiatry, 34, 54 58 Schmidt, U.H., Tiller, J.M & Treasure, J.L (1993a) Setting the scene for eating disorders: Childhood... evaluation of self Dietary restraint 4 Shape and weight-based self-esteem Disgust of food and body stimuli 3 Bodily shame Onset of eating disorder Figure 9.1 Putative model for psychological factors in eating disorders 162 LUCY SERPELL AND NICHOLAS TROOP propose is that these background factors (or some combination of them, depending on the eating disorder subtype) represent an increased risk of eating disorders. .. 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