A Biopsychosocial Approach to Eating Disorders

Why I Chose This Topic

Purpose

• I chose this topic because I remember reading a statistic that anorexia nervosa has the highest mortality rate of all psychological disorders. After reading that statistic, I thought it would be interesting to develop a deeper understanding of the biological, psychological, and social factors that influence this disorder. Additionally, when beginning to research this topic, I found that many people who fall ill to eating disorders often have other concurrent disorders as well. I always am willing to learn more about mental illnesses and their concurrent disorders so I can further advocate these issues and help reduce the stigma around mental health.

Inquiry Question

How can eating disorders be explained using a biopsychosocial approach?

Subquestions to Guide Research

• What biological, psychological, and social factors play a role in the development of eating disorders?
• What other disorders exist concurrently with eating disorders?
• What treatment options are there for individuals suffering from an eating disorder?

The Biopsychosocial Model

(Lehman, David, and Gruber, 2017)

What is the biopsychosocial model?

• The biopsychosocial model was created by George Engel in 1980 and emphasizes that health and disease are a multifactorial concept. In other words, biological, psychological, and sociocultural forces are dynamic and act together to determine an individual’s health and vulnerability to disease (Lehman, David, and Gruber, 2017).

Biological Dynamics

(Lehman, David, and Gruber, 2017).

What is meant by biological dynamics?

• Biological dynamics include the physical aspects of the body that influence and determine health.
• This can include an individuals immune and cardiovascular system, which are essential to the health of the entire body, as well as their neural systems which play a role in understanding the psychological and physical elements of health.
• Gene-environment interactions, social genomics and epigenetics, and psychoneuroimmunology all play integral roles in the biological dynamic that constitutes the biopsychosocial model.

Psychological Dynamics

(Lehman, David, and Gruber, 2017).

What is meant by psychological dynamics?

• Psychological dynamics can include cognitive, emotional, motivational, attitudinal, and behavioral systems that influence health.
• They include the role of self, identity, personality, coping strategies, substance use and addiction, stress appraisal, emotions, and health behavior in understanding physical and mental health.

Social (interpersonal) dynamics

(Lehman, David, and Gruber, 2017).

What is meant by social (interpersonal) dynamics?

• Interpersonal dynamics concern the actual or perceived social contacts of health. These social dynamics often include direct contact with others and the consequences of others’ actions.
• This can include an individuals’ family influences, work environment, peers, and community health resources.
• Additionally, social dynamics can include concepts such as socioeconomic status, culture, and gender perspectives

Critique of Lehman, David, and Gruber (2017)

Critique of Lehman, David, and Gruber (2017)

• The article by Lehman, David, and Gruber (2017) provides a review of George Engel’s biopsychosocial theory and expands on this model my recognizing that each of these influences varies within an individual throughout their life. Barbara Lehman (PhD in Social Psychology at Western Washington University) does an excellent job at summarizing Engel’s theory as well as using this method to analyze two case-studies highlighted in the paper. She stresses the implication of this model in health, theory, research, and policy making and how this theory attempts to encapsulate the entirety of an individuals lived experience to further understand their health.

Supports of this model (Wade and Halligan, 2017).

Supports of this model

• Used as the basis of the World Health Organization’s International Classification of Functioning, and is used clinically, as well as to structure clinical guidelines.
• Leads to person-centered care which can improve patient outcome.
• Used as a theoretical basis for validated measures.
• Most widely mentioned and used model in research into rehabilitation and disability for chronic pain and psychiatric disorders.
• Identifies different levels of an illness, a hierarchy of systems that is supported by empirical studies of inter-relationships between different components of an individuals life.
• Provides rationale for treatments such as cognitive-behavioural therapy.

Critique of Wade and Halligan (2017)

• Derick Wade is a Professor of Neurological Rehabilitation at Oxford Brookes University while Peter Halligan has his PhD in Cognitive Neuroscience at Cardiff University . The purpose of this article is to shed light on the importance of implementing the biopsychosocial model into all aspects of healthcare management. This article highlights only the positive outcomes of using this model in healthcare while not acknowledging some of the limitations it may pose. Additionally, it emphasizes the major problems that may arise in the healthcare field when adopting the biomedical model of health.

Criticisms of the biopsychosocial model

(Benning, 2015)

Criticisms of the biopsychosocial model

• It lacks philosophical coherence. It is argued that Engel may have not followed the system and complexity theories that he claimed to be influenced by that closely. It may never be possible to know all factors to a given health outcome.
• It adopts eclecticism, meaning one can emphasize the ‘bio’ component if one wishes, or the ‘psycho’, or the ‘social’ which subsequently leads to anarchy.
• Fails to honor subjectivity (such as an individual’s personal meaning and spirituality)
• Applicable to several healthcare fields but has not been adopted by more economically dominant and politically powerful medical and surgical fields

Critique of Benning (2015)

• Tony B Benning is a Clinical Instructor at the Maple Ridge Mental Health Office in the Department of Psychiatry at the University of British Columbia. Benning summarizes various limitations of the biopsychosocial model in psychiatry. He does a great job at highlighting the various criticisms that have arose since the development of the biopsychosocial model (which were mentioned earlier). However, I found that he fails to mention the variety of breakthroughs that this model has provided in the field of psychiatry, and focuses only on the flaws of this model.

Anorexia nervosa

(American Psychiatric Association, 2018)

What is anorexia nervosa?

• Anorexia nervosa is diagnosed when patients weigh less than 15% of the normal healthy weight expected for their height.
• This eating disorder is characterized by minimal food intake, fear of becoming “fat” and body image dissatisfaction or denial of low body weight.
• The reason people with anorexia do not maintain a healthy body weight is due to the fact that they refuse to eat enough, often exercise excessively, and may force themselves to vomit or use laxatives to lose weight

Bulimia nervosa

(American Psychiatric Association, 2018)

What is bulimia nervosa?

• Individuals with bulimia may frequently diet and exercise obsessively and can be either underweight, normal weight, overweight, or even obese; however, they are not as underweight as individuals diagnosed with anorexia. This makes it difficult to identify an individual suffering from bulimia nervosa.
• Bulimia nervosa is characterized by frequent binge eating in which individuals eat a large amount of food in a short period of time and feel as if they are out of control. This often involves consuming thousands of calories, of which are high in sugars, carbohydrates and fat.
• The binge eating is usually interrupted by another person or by falling asleep because their stomach hurts because it is stretched beyond capacity.
• Following a binge eating episode, stomach pain and fear of becoming fat are common reasons as to why an individual will purge by throwing up or taking laxatives.
• This vicious cycle is often repeated various times a week, and in more severe cases, several times a day.

Binge eating disorder (American Psychiatric Association, 2018)

What is binge eating disorder?

• Binge eating disorder is characterized by consumption of large quantities of food in a short period of time in which the individual feels out of control.
• The difference between a binge eating disorder and bulimia is that people suffering from a binge eating disorder do not purge afterward, often leading to serious health complications such as obesity, diabetes, hypertension, and a wide array of cardiovascular diseases.

Critique of American Psychiatric Association (2018)

• The American Psychiatric Association is the primary professional organization of psychiatrists in the United States. Their website provides very useful unbiased information on eating disorders as well as a wide variety of other psychiatric disorders. They provide very accessible information on these disorders, the symptoms of these disorders, and event treatment options. That being said, I did not find much information on their website about the biological or social components which may constitute eating disorders.

Gender (Schaumberg et al., 2017).

Gender

Eating disorders affect both male and females

• Men and women may vary in their clinical characteristics
• Men are thought to be less likely to seek treatment for eating disorders
• Men are less likely to be diagnosed with an eating disorder, even with identical symptoms as a women

Age

(Schaumberg et al., 2017)

Age

• The typical age of onset for anorexia and bulimia is in adolescence and early adulthood. Binge eating disorder also begins around this time as well.

Race and Ethnicity (Schaumberg et al., 2017)

Race/ethnicity

• In the United States, the prevalence of eating disorders in ethnic and racial minority groups is similar to that of the white population. It is important to note, however, that ethnic minority groups report binge-eating behavior more frequently

Sexual Orientation and Gender Identity (Schaumberg et al., 2017)

Sexual Orientation and Gender Identities

Homosexuality is regarded as a risk factor for eating disorders in men

• Gay and bisexual men report more body dissatisfaction and disordered eating than heterosexual men.
• 16% of transgender youth reported being diagnosed with an eating disorder in the past year, compared to 2% of cisgender men and 4% of cisgender women

Socioeconomic Status

(Schaumberg et al., 2017)

Socioeconomic Status

• There is no relationship between socioeconomic status and risk for eating disorders

Heritability and Genetics

(Yilmaz, Hardaway, and Bulik, 2016).

Heritability and Genetics

• Heritability estimate for anorexia nervosa obtained from twin studies ranges from 0.48-0.74. In other words, up to 74% of phenotypic variation can be explained by additive genetic factors, while the other 26% can be explained by environmental factors.

• Heritability of bulimia nervosa was found to be 0.55-0.62 in twin studies.

• Heritability of binge eating disorders was determined to be between 0.39-0.45 from observed twin studies.

Biologically Influenced Personality Traits (Schaumberg et al., 2017).

Biologically Influenced Personality Traits

• These traits are influenced by genetic factors, exist premorbidly, and become exacerbated during acute stages of illness while persisting after recovery, and may or may not influence the prognosis of eating disorders
• Some of these traits include obsessive thinking, perfectionism, neuroticism, rigidity and persistence, as well as impulsivity.

Atypical Response to Eating and Activity

(Schaumberg et al., 2017).

Atypical Response to Eating and Activity

• Individuals with eating disorders may have a different response to energy restriction and food consumption
• Caloric intake may be associated with a dysphoric mood while caloric deficits may evoke a calming or euphorigenic effect

Dysregulation of Neurotransmitters

(Schaumberg et al., 2017).

Dysregulation of Neurotransmitters

Eating disorders are associated with dysregulation in neurotransmitter availability and function

• Findings of positron emission tomography (PET) found dysregulation in both dopaminergic and serotonergic systems in individuals with eating disorders.
• Both of these systems are critical in the rewarding aspects of food, motivation, executive functions, and the regulation of mood, satiety, and impulse control

Brain Structure and Function

(Schaumberg et al., 2017)

Brain Structure and Function

Brain structure and function differ between those with active eating disorders and unaffected individuals

• Altered reward pathways, manifesting impaired regulation of appetite, emotion, self-control, and interoception.
• People with anorexia have altered activity in anterior insula, which is associated with self-awareness. That being said, individuals with anorexia may not recognize when they are hungry

Endocrine System (Schaumberg et al., 2017).

Endocrine System

Endocrine changes are associated with risk of developing an eating disorder

• The risk of eating disorders increases during reproductive milestones, such as puberty and pregnancy in females, and sex hormones play a role in this risk.

Critique of Schaumberg et al.,(2017)

In 2015, the Academy for Eating Disoders collaborated with international patients, advocacy, and parent organizations to craft the 'Nine Truths About Eating Disoders' to erradicate stereotypes about eating disorders and replace them with factual information. Katherine Schaumberg is an assistant professor and clinical psychologist who specializes in research assessment and treatment of eating disorders. She obtained her PhD from Albany-State University of New York. This article focuses on the science backing up the nine truths about eating disorders. This article provides a wide variety of information on eating disorders and debunks common myths about eating disorders. This article recognizes the need for more funding and more definitive collaborative studies to reduce conflicting results from small, underfunded, underpowered, and non-replicated investigation. Eating disorders are often considered a low priority illness because of the misconceptions about their causes and consequences

Perfectionism

(Riviere and Doulliez, 2017; Stoeber et al., 2017)

Perfectionism

Perfectionism, more specifically maladaptive perfectionism, is related to negative psychosocial outcomes and is a strong risk factor for the development of eating disorders (Stoeber et al., 2017).

• Perfectionism is a personality trait characterized by striving for exceedingly high standards of performance accompanied by self-criticism and concerns over negative evaluations by others.
• Self-oriented perfectionists have exceedingly high personal standards, strive for perfection, expect to be perfect, and are highly self-critical if they fail to meet these expectations.
• Socially prescribed perfectionists believe that others expect them to be perfect, and that others will be highly critical of them if they fail to meet their expectations.
• Perfectionism plays a role in the development and maintenance of eating disorders by predicting an over-evaluation of eating, shape, and weight and their control in the evaluation of the self, which in turn leads to strict dieting and other weight-control behaviors (Riviere and Douilliez, 2017).

Body Image Dissatisfaction

(Manaf, Saravanan, and Zurah, 2016).

Body Image Dissatisfaction

Body image can be defined as an individual’s perception of his or her own physical appearance

• Body dissatisfaction is the inability to accept one’s body image and is often associated with the development of disordered eating, to achieve what is considered an ideal physique.
• Development of body image dissatisfaction can lead to unhealthy preoccupation, obsessions, and distorted perception of body image.
• Having unrealistic expectations of ones’ body image increases the probability of body dissatisfaction and a greater risk in development of eating disorders.

Sense of Self

(Bardone-Cone, Thompson, and Miller, 2018)

Sense of Self

A variety of self-related constructs have been theoretically and empirically linked to the development and course of eating disorders. For this project I am going to focus on self-esteem as well as self-efficacy.

Social Media and Eating Disorders (Rodgers et al., 2020)

Social Media

• Social media use has increased among adolescent boys and girls in recent years and has been associated with and predictive of body image concerns and disordered body change behaviors.

• Exposure to appearance-focused media content may be associated with higher levels of internalization of appearance ideals, that is, the endorsement of appearance ideals as a personal standard.

• In turn, this can influence an individual’s body image perception and lead them to engage in disordered eating behaviors and muscle building behaviors in pursuit of these ideals.

Acculturation (Saunders, Frazier, Nichols-Lopez, 2016)

Acculturation

• Acculturation has been cited as a component to disordered eating, with acculturative stress leading to an increase in body dissatisfaction and bulimic behavior

• Individuals who have spent more of their lifetime in the USA, compared to their country of origin, display higher levels of dissatisfaction, thin-ideal internalization, and eating disorder pathology.

• Research suggests that high rates of disordered eating exist among racial and ethnic minorities

Becker (2004) recalls the rise in eating disorders in Fiji in response to the introduction of television in the mid to late 1990's. After the introduction to television, symptoms of disordered eating became more prevalent .

• 74% of women felt "too fat"
• 69% dieted to lose weight
• 11% used self-induced vomiting
• 29% were at risk for clinical eating disorders

Bullying and Eating Disorders (Lie, Ro, and Bang, 2018).

Bullying

Being victimized through bullying and teasing is associated with a higher prevalence of eating disorders, and is therefore considered a risk factor

• Being teased and bullied during childhood and adolescence is associated with adverse health outcomes, including psychosomatic problems, emotional problems and depression, psychotic symptoms, and suicide
• Moreover, being teased for one's appearance is associated with body dissatisfaction, dietary restraint, and bulimic behaviors
• Compared to healthy controls, individuals with eating disorders were two to threefold significantly more likely to have been teased about their appearance and bullied prior to onset of their ED

Medical Complications and Suicide (Schaumberg et al., 2017)

Medical Complications and Suicide

The most significant medical complication of eating disorders is premature death

• Risk of death for individuals with anorexia is approximately six times greater than that of the general population
• Risk of death for individuals with bulimia is about two times higher than that of the general population

Risk of suicide attempts is also elevated in individuals with eating disorders (approximately five times more than that of the general population)

Cognitive Behavioral Therapy

(Bardone-Cone, Thompson, and Miller, 2018)

Cognitive Behavioral Therapy

Focuses on over-evaluation of weight, shape, and eating control with the goal of changing dysfunctional thoughts and beliefs about the role one's weight and shape plays in self-concept

• This method challenges dysfunction system of self-evaluation and decreases strict dieting and other weight control behaviors
• This is often the treatment of choice for treating bulimia nervosa

Interpersonal Therapy

(Bardone-Cone, Thompson, and Miller, 2018)

Interpersonal Therapy

The goal of interpersonal therapy is to create or recover healthy interpersonal functioning, making the eating disorder behaviors irrelevant by feeling connected to others

• Thought to improve self-evaluation and self-esteem

Family Based Treatment

(Bardone-Cone, Thompson, and Miller, 2018)

Family Based Treatment

Family based treatment uses family members as resources and empowering them to help adolescent patient recover

• This allows the disorder to be externalized and therefore conceptualized as something distinct from adolescent's identity
• Initially, parents are coached to find the best ways to control their child's eating behavior.
• In the next phase, the external control is removed and autonomous eating behavior is linked to long-term resolution of eating disorder
• Often used to treat anorexia nervosa

Mindfulness Based Approach

(Bardone-Cone, Thompson, and Miller, 2018)

Mindfulness Based Approach

Mindfulness based treatments are characterized by attending to the present moment as well as a general attitude of acceptance, rather than judging and attempting to modify an individuals experience

• Orient individuals to live in accordance with their life values,
• Helpful in addressing eating disorders by targeting eating disorder behaviors specifically or making changes in one's sense of self

References

National Eating Disorders Collaboration (2020). Psychiatric Comorbidity and Mortality. Retrieved (2020, August 2) from https://www.nedc.com.au/eating-disorders/eating-disorders-explained/types/comorbidity/

Rivière, J., & Douilliez, C. (2017). Perfectionism, rumination, and gender are related to symptoms of eating disorders: A moderated mediation model. Personality and individual differences, 116, 63-68.

Rodgers, R. F., Slater, A., Gordon, C. S., McLean, S. A., Jarman, H. K., & Paxton, S. J. (2020). A biopsychosocial model of social media use and body image concerns, disordered eating, and muscle-building behaviors among adolescent girls and boys. Journal of Youth and Adolescence, 49(2), 399-409.

Saunders, J. F., Frazier, L. D., & Nichols-Lopez, K. A. (2016). Self-esteem, diet self-efficacy, body mass index, and eating disorders: modeling effects in an ethnically diverse sample. Eating and Weight Disorders-Studies on Anorexia, Bulimia and Obesity, 21(3), 459-468.

Schaumberg, K., Welch, E., Breithaupt, L., Hübel, C., Baker, J. H., Munn‐Chernoff, M. A., ... & Hardaway, A. J. (2017). The science behind the Academy for Eating Disorders' nine truths about eating disorders. European Eating Disorders Review, 25(6), 432-450.

Stoeber, J., Madigan, D. J., Damian, L. E., Esposito, R. M., & Lombardo, C. (2017). Perfectionism and eating disorder symptoms in female university students: The central role of perfectionistic self-presentation. Eating and Weight Disorders-Studies on Anorexia, Bulimia and Obesity, 22(4), 641-648.

Thornton, L. M., Mazzeo, S. E., & Bulik, C. M. (2010). The heritability of eating disorders: methods and current findings. In Behavioral neurobiology of eating disorders (pp. 141-156). Springer, Berlin, Heidelberg.

Wade, D. T., & Halligan, P. W. (2017). The biopsychosocial model of illness: a model whose time has come.

Yilmaz, Z., Hardaway, J. A., & Bulik, C. M. (2015). Genetics and epigenetics of eating disorders. Advances in genomics and genetics, 5, 131.