Sunday Smorgasbord: The Return

That's right, everybody. It's the return of the weekly smorgasbord of eating disorders research and news from the past week that didn't make it into my blog. Some of these tasty tidbits might not have had enough information to warrant their own post; others were neglected because I got sidetracked, busy, or otherwise preoccupied. If you follow me on Twitter (you do follow ED Bites on Twitter, right?), I probably will have mentioned some of these links, but this is my time to provide a little insight and discussion using more than 140 characters.

Attitudes of patients with anorexia nervosa to compulsory treatment and coercion

The topic of coercion and force in the treatment of eating disorders is rather contentious; for my previous thoughts on the subject, click here, and Dr. Sarah Ravin recently addressed the topic as well. Some interesting research has been going on in recent years to determine how people with AN ultimately feel about compulsory treatment and coercion. The answers are a bit surprising. Although people tend to have a negative view of compulsory treatment in the moment (which really is to be expected), this view changes as time passes and many patients recognize the necessity of hospital care.

In this study, the researchers interviewed a group of women who were currently suffering or had recently suffered from AN and found that:

Compulsion and formal compulsory treatment of anorexia nervosa were considered appropriate where the condition was life-threatening. The perception of coercion was moderated by relationships. What mattered most to participants was not whether they had experienced restriction of freedom or choice, but the nature of their relationships with parents and mental health professionals.

Explicit vs. implicit body image evaluation in restrictive anorexia nervosa

First off, we need to understand the exact difference between explicit and implicit (Note: do not just Google explicit and hope for a will find a different kind of "explicit" waiting for you). According to the Grammar Guide,

Explicit means clearly expressed or readily observable. Implicit means implied or expressed indirectly.

This study looked at whether the preference for an ultra-thin shape stemmed from a desire to be ultra-thin, or more of a fear of overweight. The researchers found that it seemed the latter was the most true for people with AN. Not that all anorexics are fat-hating monsters, but fat phobia is a feature of a sizable portion (though not 100%) of those diagnosed with anorexia.

In contrast to the control group, the patients did not show a positive attitude toward the ultra-thin body shape on the automatic level. The AN group both on the automatic and the self-reported levels evaluated the overweight body as negative. Depression and anxiety did not influence body evaluation. Strong negative evaluation of overweight appears to be a key issue in AN rather than positive evaluation of ultra-thin role models.

Day hospital programmes for eating disorders: a review of the similarities, differences and goals

I'm a big supporter of evidence-based treatment, whether for eating disorders or cancer. Evaluating ED treatment has its difficulties, some of which include treatment dropout, and the difficulties in comparing apples to apples. This review of day hospitalization (DH) programs (also known as partial hospitalization programs, PHP) found that it's very difficult to evaluate treatment programs since they are all so different--and this is with nationalized health care, so I can imagine that doing these comparisons in the US would provide even more disparate results.

The researchers found that most day treatment programs seemed "largely experimental" due to the large number of differences in programming.

Briefly, the shared elements are: biopsychosocial model as reference frame; cognitive-behavioural model or techniques; behavioural contract; patients' selection; body image therapy; involvement of family; weight normalisation/weight gain and modification/normalisation of eating behaviour as objectives. Nonetheless, shared opinions concerning inclusion criteria are lacking; the duration of DH treatment is surprisingly different among centres (from 3 to 39 weeks); the approach to eating and compensation behaviours ranges from control to autonomy; followup and psychometric assessment can be either performed or not; psychological and behavioural objectives can be different. This review suggests the existence of two different DH models: the first has a shorter duration and is mainly symptom-focused; the second is more individual-focused, has a longer duration and is focused on patients' relational skills, psychodynamic understanding of symptoms and more gradual changes in body weight. Further investigation is required to make DH treatment programmes measurable and comparable.

This study only underscores the difficulties in not only designing evidence-based treatment programs for EDs, but then being able to evaluate different treatment modalities for efficacy. But not doing this job would be a disservice to millions of people.

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Adrianna said...

How funny! I was just thinking this morning, "Whatever happened to the smorgasboard?"

Anyway, I really like the segment about how people with AN aren't attracted to an ultra-thin body shape so much as they are trying to avoid being overweight. Being too thin allows them to be SURE that they aren't getting fat.

Yes, it could be an invaluable insight into what's going on in the heads of AN patients and how to treat them. However, I also think it could be helpful to the publilc at large, first of all because it makes AN look less vain. Poring over altered magazine photos is a stereotypical shallow, immature behavior that we associate with young teens, and we look down on people like that. Trying not to be overweight, however, is very different in the minds of the public. It's an attempt to have control over yourself. Control is good, right? They are trying to be healthy, and healthy means thin, athletic, and an obsessive dieter, right? All of a sudden, AN becomes understandable.

Second, and this ties into the first point, if people realize that for many peoeple, AN is more about not being fat than it is about being skinny, they might reconsider the obesity hysteria. Who knows how many people would seek help sooner or not start dieting to begin with if we did not demonize fat or demean fat people. This idea that fat is unhealhy and evil is THE fuel for the fire for a lot of eating-disordered people, and it needs to stop.

Just my two cents.

Carrie Arnold said...


All I have to say is "right on!"

Thanks for all of your insightful comments.

Cathy (UK) said...

Having written a published personal account of my experiences of longstanding restricting anorexia nervosa (AN) titled 'Anorexia Nervosa and the Body Image Myth' ( I am very keen that researchers explore the explicit and implicit role of not just 'body image' in AN, but also the meaning of anorexic behaviours to the affected individual.

The paper cited in this Sunday Smorgasbord is interesting, and I haven't yet read the full paper; however I do note from the Abstract that the authors state "The first aim of the study was to examine whether an ultra-thin ideal or negative attitudes toward overweight might be the motivation behind pathological restriction"... (Note the 'either' or 'or'...).

Now, what (I feel) they should also be considering is that perhaps 'body image' concerns are not necessarily central to the psychopathology of (restricting) AN...

Nowadays it is almost taken for granted that AN is caused by body dissatisfaction, distorted 'body image' and/or fat phobia - in part because that is how anorexic behaviours are interpreted by others. Researchers need to be broader minded and not to simply assume that because a person is restricting food that they (must surely) wish to change their body shape or to remain very thin - and that is why they have AN.

Actually, one of the biggest drawbacks in ED research nowadays is the over-use of numerous closed questionnaires (albeit 'validated') which demand (from patients) fixed answers to fixed questions. I have found that the few qualitative studies of patients' experiences of AN (i.e. studies that use research methods which allow patients to freely express their thoughts and feelings without prompting) produce more meaningful, and often different data.

N.B. I agree with Adrianna (above) that obesity hysteria and the plethora of healthy eating/exercise reports in the media is unhelpful for kids with the inherent psychological profile that makes them vulnerable to developing AN.

Katie said...

Thank you for this Carrie, a weekly round up of research was such a good idea and it's good to see it back! I agree with Cathy (what a surprise!) on the body image issue. I remember when I left treatment the first time around, my discharge questionnaire scores showed very little difference to the ones I completed when I started going there as an outpatient. I didn't worry about my size/weight/shape to start off with and I am phobic of being sick so I never binged or purged, so the only things anyone had to go on for improvement was my weight (which was much the same as it had been 18 months previously) and my intake (which was...much the same as well). Despite not apparently showing any of the 'typical' psychological symptoms of anorexia according to their questionnaires I had been very ill during treatment, and I went on to relapse to a much worse extent after I left. It would be great if it wasn't just assumed (not by you, but by many researchers and professionals) that all people with eating disorders attribute the same thought processes and concerns to their behaviours.

I'm pleased that day treatment is beginning to get some attention from research, I'm a big fan of it!

Cassidy said...

I cannot tell you how happy I am to see the return of the "smorgasboard". The research on compulsary treatment is so interesting, and even though I've seen my friends and myself go through that same thought process it's uber nice to have something out there to back you up. I think studies like this are going to be seeing a lot more attention soon, and hopefully they'll help parents and loved ones realize that treatment doesn't take someone's freedom away, it gives them a chance to actually use it.

Kudos Carrie!

Carrie Arnold said...

Cathy and Katie,

Thank you both so much for helping to clarify the "body image" issue in AN. You're right- many researchers assume it's a given when it's not. It also goes to show that a large number of people would be left out of eating disorder prevention programs if they only focused on body image. Deconstructing the media is a good thing, but poor body image isn't the only factor in AN.

Cathy (UK) said...

Thanks for your response Carrie :)

I think the concept of ED prevention is an interesting one... I'm not sure if you've blogged on that topic before because I only discovered your blog (which I love) a couple of months ago...

Can EDs REALLY be prevented?

Perhaps some EDs can be and the answer to this question depends on the type of ED... However, it has been suggested by some that anorexia nervosa is triggered by the hormonal changes of puberty in some people (and how sex hormones influence brain function, thought processes, desires for food, sex etc). The weight loss of anorexia nervosa often inhibits or reverses puberty and so returns the body and brain to a state that is perceived by the individual as 'safe'.

How potent, therefore, are environmental or social triggers?

Carrie Arnold said...


ED prevention is an interesting topic; thus far, most prevention programs aimed at educating students about the dangers of EDs seems to have the opposite effect: it provides a "guidebook" of sorts. ED education is probably better aimed at parents, caregivers, and other adults so they can look out for the kids.

Most other evidence-based prevention programs are based more on improving body image and self esteem than preventing eating disorders, per se. I am in favor of this type of education because I think it's helpful for anyone, whether they have the genetic makeup for an ED or not. Do I really think they prevent eating disorders? I'm doubtful. To be bluntly honest, I don't know how effective any ED prevention program is going to be because of the strong biological basis. Personally, I would like to see more work done in early recognition of eating problems and a normalization of our culture's messed-up attitudes toward food (because the beginnings of an ED totally blend in with normalized dieting, and it certainly fostered a disordered attiude about food and weight).

Disease prevention is a noble goal, but even my limited experience in public health has shown me that it's very difficult and very complicated.

Cathy (UK) said...

Thanks again for the insight Carrie...

In the UK there has been a thrust towards educating girls to be 'media savvy' with the objective of preventing EDs; i.e. they are taught to be aware that many media images of slim, beautiful women are digitally altered and that these 'unreal' women are not as healthy as 'real' women... And then, of course, we have the 'Dove Campaign for Real Beauty'....

It's all well meaning but possibly/probably futile... actually like so many public health interventions. I do wonder how many professionals really believe in these interventions, or whether they just become involved for publicity or sponsorship/research grants/kudos...

Personally, I have never considered anorexia nervosa to be a simple extension of normal female (or male) concern about 'looking good' - even in individuals who have the fat phobic variety. Rather, I believe that individuals with fat phobic anorexia nervosa genuinely do have a brain that is 'wired for detail' such that they focus obsessively on certain body parts, or on the symmetry of the body as a whole (i.e. akin to treating the body as an 'object' rather than a collection of organs that operate to allow the maintenance of homeostasis and life).

In the same vein I believe that body dysmorphic disorder may be explained by abnormalities in information processing.

Surely these disturbances of 'body image' are biologically mediated rather than culturally mediated? That is, the disturbance is specific to the individual and/or elicited through starvation?

Alternatively, if a person is teased about their body, or sexually abused, they may develop a fixation with their bodies, or despise their abused body.

And finally, obsessive and perfectionistic kids who take media messages about health very literally, and are genetically/biologically pre-disposed to develop an ED may become terrfied that if they (e.g.) consume anything with fat in it, or if they don't exercise for x minutes every day.... and very soon they're trapped in a pattern of OCD-driven disordered eating/exercising....

Blah, I ramble....

Carrie Arnold said...


I really don't have much to add- you are just so spot on (have I mentioned how much I enjoy your thoughts and insights and how much I think it adds to my blog?).

I have been meaning to blog about similarities and differences between EDs, OCD, and body dysmorphic disorder. I don't know that these three are identical disorders, but there is almost certainly some overlap in the neural circuitry.

Cathy (UK) said...

Thanks Carrie :) I was actually conscious of writing too much on your blog, but I love these academic debates - and you feed our brains!

The point is that my recovery from 30 yrs of anorexia/over-exercise has been greatly aided by studying my illness and studying myself. I have ALWAYS felt that anorexia nervosa is a brain illness. I said that to my mother when I was 12 yrs old. She asked me why I was starving myself and over-exercising and I told her that "this thing in my head makes me do it". I guess it was a kid's way of describing severe OCD...

Anonymous said...

I knew that I looked terrible when I was anorexic; I just didn't want to eat.

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I'm a science writer, a jewelry design artist, a bookworm, a complete geek, and mom to a wonderful kitty. I am also recovering from a decade-plus battle with anorexia nervosa. I believe that complete recovery is possible, and that the first step along that path is full nutrition.

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