CAUSES OF EATING DISORDERS: THEORIES AND PERSPECTIVES

The complexity of EDs challenges psychiatric nurses to have Some basic understanding of causative
factors. There are three different theories about the cause of EDs. They are derived from biological,
psychodynamic, and psychosocial perspectives.

Biological Factors
The most common ED is bulimia nervosa in women who maintain normal weight. These women exhibit
symptoms usually found in women with AN, such as disturbed appetite, abnormal body image,
depression, and neuroendocrine changes that precipitate menstrual irregularities. However, because
these women are of normal weight, the changes cannot be attributed to weight loss.

Brewerton's extensive research (1995) postulates a unified theory of 5-HT dysregulation in clients with
eating and related disorders. Clients with ED exhibit several clinical features and biologic findings
indicative of 5-HT dysregulation as well as a failure of neurotransmitter regulation, rather than a simple
increase or decrease in activity. These include feeding disturbances, depression and suicidal behavior,
impulsivity and violence, anxiety and harm avoidance, obsessive-compulsive features, substance abuse,
seasonal variation of symptoms, disturbances in neuroendocrine and vascular tissues, and
neurochemical systems linked to 5-HT such as temperature. Research review supports a 5-HT
dysregulation hypothesis and that a variety of psychobiological stressors, such as dieting, binge eating,
purging, drug abuse, and photoperiodic changes, as well as psychosocial-interpersonal stress, perturb a
vulnerable 5-HT system. The interaction with a variety of psychobiological stressors perturbs the
vulnerable 5-HT system, leading to further dysregulation. Review Chapter 3 to help understand the
Behavioral-Biological Interface to give further understanding of Brewerton's theory of 5-HT dysregulation
hypotheses. See Table 21-3 for the interaction of stressors with a vulnerable 5-HT system. A twin study
estimated the heritability of AN to be 58 percent, with the remaining variance apparently caused by the
non-shared environment (Fairburn et al., 1999). In the female client with AN, there are complex
disturbances in reproductive biochemistry that may affect her ability to ovulate and become pregnant.
The prolonged period of starvation has implications for the health of the developing fetus.

5-HT Dysregulation Hypotheses of Eating Disorders: Interaction of Stressors with Vulnerable 5-HT
System

 Dieting; fasting
 Binge eating
 Purging; dehydration
 Compulsive exercising
 Alcohol and drug use
 Photoperiodic changes
 ED clients exhibit disturbances in other neuro-chemical systems linked to 5-HT, including:
o Hypothalmic-Pituitary Adrenal (HPA) axis
o Noradrenergic system – Dopaminergic
o Isatin, an endogenous MAO-like compound
o Neuropeptides, e.g., B-endorphin, dynorphin, cholecystokinin, neuropeptide Y and YY,
galanine, arginine, vasopressin
 o Leptin

Psychodynamic Factors
Bruch believed that anorexia and bulimia were related to "underlying deficits in the individual's sense of
self-identity and autonomy" (1982, p. 1532). She was the first to formally suggest that there was an
actual disturbance of body image in AN. Bruch (1962) stated that "what is pathognomonic of anorexia
nervosa is not the severity of the malnutrition per ... but rather the distortion of body image associated
se... with it: the absence of concern about emaciation, even when advanced" (p. 187). She believed that
the extreme denial of the emaciation was an expression of a delusional disturbance in body image.

Body image disturbance is an essential characteristic of AN. Although it is related to a more generalized
misperception of internal states, such as hunger and emotions, it specifically involves the inability of the
client with anorexia to identify her appearance as abnormal. This misperception can be extremely
dangerous because it can become almost delusional as the client with anorexia defends an emaciated
body shape.

In the psychoanalytical framework, EDs are viewed as a form of neurosis representing a regression to the
oral stages of development. Just as Freud connected oral drives and sexual drives, Bruch (1973)
expounded on his connection when she addressed the abhorrence of the client with anorexia to her own
sexuality.

Psychosocial Factors
Psychosocial factors associated with eating disorders often mediate various biological and genetic
factors. Because of the high comorbidity of other psychiatric disorders, it is highly likely that various
psychosocial factors, such as chaotic or dysfunctional family dynamics, culture, deprivation, and trauma
play are linked to eating disorders (Strober et al., 2000).

Familial Factors

The genesis of EDs may be viewed from a family systems theory framework. Ideally, the family is to
provide a child with the nurturance and opportunities needed to develop as an individual. This is done
through parental guidance and promotion of the autonomy needed in adult life. Family systems theorists
view the family interactions of the family system in which there is a member with anorexia or bulimia as
discouraging the development of independence and autonomy. This results in a self-perception of
powerlessness and helplessness on the part of the child. This theory views a pattern of unconscious
collusion where the family "agrees" to divert the conflict onto the symptomatic family member
(Minuchin, Rosman, & Baker, 1978)

Minuchin et al. (1978) have identified characteristics often in the families of children with eating
disorders as enmeshment, overprotectiveness, rigidity, and lack of inter-present actions of the child and
the family. Finally, Minuchin et al. (1978) addressed the rigidity within these families, which refers to
their inflexible nature and their desire to maintain the status quo. The lack of conflict resolution refers to
the family's inability to negotiate any type of compromise or any kind of solution to an identified
problem. Family conflicts are usually polarized into a "win or lose" situation, with no one wanting to be
on the losing end (see Chapter 27). Transgenerational perspectives take into account the transmission of
anxiety and dysfunctional patterns that the family system has of relating over generations, with the
triangulation of symptoms onto one or more vulnerable family members. Usually, there is a pattern of
poor differentiation from grandparents and difficulty in parental marriage. These "family legacies" can be
viewed as the experiential portion of family belief systems that evolved because family organization
shifts and changes over time. In the bulimic family, the multigenerational legacy revolves around weight,
attractiveness, fitness, success, and eating of food. Usually, there is a pattern of poor differentiation from
grandparents and a belief in filial loyalty coupled with success (Roberto, 1986; 1992). Recent research on
adolescents' perceived experience of family pressure (Horesh et al., 1996) underscores the observation
that EDS stem from dysfunctional family functioning. The patterns of relating in families with ED may be
appreciated in the following excerpt (Horesh et al., 1996):

"One night, my mother came alone. This was potentially dangerous. My father acted as a buffer between
us, I acted as a buffer between them, and my mother was between my father and I. Classic triangulation.
A house of cards depends on the stasis of each; pull one out, and ashes, ashes, we all fall down.... In
therapy, it had come to my attention, despite my adamant insistence that my mother was immortal and
lived on Mount Olympus, that my relationship with her was perhaps less than perfect... that I might have
picked up some of my neuroses about food from my mother... I mentioned that she was per- haps a bit
over concerned with her own body, her weight, how much she ate. She sat arms crossed... smiling a
patronizing smile. I pressed her. The smile turned nasty, and she announced that I had no business
blaming her for my problems. I said, I'm not blaming you, I'm just saying I might have picked up some
habits-She said 'Sweetheart, you didn't pick anything up' You just came this way... and picked up her
purse and walked out. I went to family therapy. legs crossed, one arm holding her waist, one hand my
mother was cold, sat back in her chair. flickering, twitching, touching the upturned collar of her shirt...
she didn't meet my eyes... pressed by the therapist, she would snap, eyes flashing, a quick stiletto to the
ribs. Father was warm, concerned, when pressed he would snap, voice rising, jaw clenching... sixteen
years of a bad marriage were swollen and pulsing under the skin, waiting to bust. My parents believed
then, that it was simply a matter of getting me fed. This is the Little-Bit Overboard- on-Her-Diet Theory.
This holds the real issue-The fact that you're dabbling in a fatal disease, on pur- pose-at bay and stalls
any meaningful progress. You don't yet know that monsters larger than diet and weight will have to be
worked through. Your family will have to look at you in a new light... not simply as their little girl-even
the parents and spouses of older eating-disordered women often display this attitude-but a human with
a history, a range of emotions.... Neither my family nor I was ready to do that yet. It was easy for us not
to. Things would never be the same. You cannot watch your child kick death's door and expect that you
will forget. You cannot tear open family wounds and hope that they will heal without a scar. Everything
changes. For better or for worse, the family fell apart. (Marya Hornbacher, Wasted: A Memoir of
Anorexia and Bulimia, 1998)

Sociocultural Factors
Obviously, we live in a diet-conscious society in which thinness is viewed as attractive and healthy.
Images and messages, both blatant and subtle, bombard young girls and women, promoting thinness,
dieting, and weight loss as attractive and associated with sex appeal and achievement. The phenomenon
of EDs has been described mainly in Western culture. where there is an extreme idealization of thinness.
It has been thought in the past that certain sociocultural groups, specifically white females, were at
highest risk for these disorders; however, current clinical practice indicates that the most assimilated
minority cultures are at as great risk as white females. This incorrect perception, that EDs are mainly a
disease of white females, has led to a general lack of awareness among clinicians and subsequent failure
to diagnose disturbed eating behaviors in minority clients. African American women report laxative and
diuretic abuses as well as fasting behaviors to avoid weight gain. Research indicates that younger, more
educated, and perfection-seeking African American women were most at risk for succumbing to these
disorders. Among Latinos, EDs are also directly related to acculturation (Fitzgibbon & Stolley, 2001).
Models, actresses, and others in the entertainment industry have a high frequency of EDs. Gymnasts and
ballet dancers are at extremely high risk. These assumptions about the incidence of EDs across cultures
are supported by cross-cultural studies. Data from repeated cross-cultural studies show that EDs are
prevalent worldwide (Nasser, 1997; Wlodarczyk-Bisaga & Dolan, 1996

In addition, there is tremendous pressure on women today to achieve in separate arenas simultaneously.
They must be successful, independent, and competitive profes- sionally while competently maintaining
their traditional role as wife, mother, and homemakers. The stressors inherent in this situation may be
overwhelming to those women who may be predisposed to EDs.

Although numerous theories about EDs exist, none can explain the current increase in their incidence.

Personality Factors
Clients with AN are described by clinicians as having specific personality characteristics, as shown in
Table 21-4.

Intimacy and Marital Issues

Issues of disturbance in sexuality and intimacy have been associated with EDS. The early experiences of
sexual and physical abuse may affect the libido, and the association with mood disorders may decrease
the libido. Persons who restrict food intake appear to have decreased libido and be

Table 21-4

Personality Factors

ANOREXIA NERVOSA (AN)

 Resistance to acknowledging they have a problem

 Obsessional thoughts about doing things right
 Hyper-rigid behaviors
 Difficulty learning from experience
 Greater risk avoidance (compared to controls)
 Emotionally restrained . Conformity to authority
 Trait obsessionality
 Inflexible thinking
  Social introversion
 Limited social spontaneity

BULIMIA NERVOSA (BN)

 Problems identifying internal states contributing to feelings of helplessness (self-regulation)

 Variable moods: fatigue and depression to agitation, which contribute to impulse control
difficulties
 Sense of loss of control related to bodily experience (probably related to early experiences with
abuse/trauma; children of alcoholic parents
 Low self-esteem, and personal efficacy, leading to self-doubt and uncertainty
 Highly self-critical and punitive in self-evaluation
 Self-conscious, sensitive to rejection from others

less interested in sex, whereas those who binge or binge and purge seem to have more frequent sexual
activity and interest. The latter is sometimes interpreted as part of the or prevent larger issue of impulse
control, but it may also be caused by age differences. Anorexia has been interpreted psychologically as a
fear of sexuality or an attempt to delay sexual development and menses. The person with ED with
obesity also experiences a fear of intimacy and may use food as a substitute. Food is more dependable
and does not evoke issues of trust and vulnerability that emerge in relationships, including marriage.
Most clients with ED experience shame and disgust with their bodies, whether they are obese, of normal
weight, or very thin. These feelings obviously inter- fere with any enjoyment or pleasure in physical
touching or joining. Additional intimacy issues include hiding or not showing their bodies to partners or
spouses and projecting feelings of disgust when looked at or touched. Some obese women have
reported much anxiety when dieting in the context of becoming more attractive and thus sexually
appealing. It would appear that the ED syndrome might provide comfort, safety, and anxiety reduction
when the client is presented with fears and conflicts of intimacy.

Populations at Risk
Persons in occupations that stress appearance and weight management as a mark of achievement, such
as models, ballet dancers, and gymnasts, are at high risk. Although women are at the highest risk,
subgroups of men include athletes (runners, wrestlers) and homosexuals (Carlat et al., 1997; Smolak,
Murnen, & Ruble, 2000; Sundgot-Borgen, 1994). Risk factors include behavioral and attitudinal factors
connected to developmental issues such as excessive weight concerns and dieting. Peer pressure,
including teasing and low self-confidence, is a risk factor, as well as worry about size, and family history
of eating or affective disorders (which may support the biological determinants of the disorder as well as
the familial determinants), in conjunction with social and peer factors. Recognition of the patterns and
risk factors of ED is crucial for early identification and school and parental education about these serious
comorbid disorders. Nurses are in pivotal positions to provide health education and pri mary prevention
in vast practice settings.