Recent Developments in the Treatment of Anorexia Nervosa

Anorexia Nervosa (AN) is a psychiatric, eating disorder characterised by three core symptoms, (a) the persistent restriction of eating leading to significantly low body weight relatively to health norms, (b) an intense fear of gaining weight or of becoming fat, or persistent related behaviours, even though one is underweight and (c) disturbance in the way one’s body weight or shape is experienced, undue influence of body shape and weight on self-regard, or persistent lack of recognition of the seriousness of the current low body weight (DSM-V, 2013).

AN is associated with more deaths than any other mental disorder. Unfortunately, its cause is unknown and there is currently no evidence-based treatment. Research on animals has been used to try to study the role of chemical messengers in the brain, such as dopamine and serotonin, that may affect how patients experience their need and desire for food, as well as their fears of gaining weight. Unfortunately, the results are currently mixed. In this context, a recent development is the study of a different chemical called ‘oxytocin’. Oxytocin is known as a ‘peptide’ that has a well-recognized role in the body. It acts as a hormone helping lactation, pregnancy and parenting. In recent years it has also been understood that oxytocin also acts like a messenger in the brain, influencing a range of social behaviors, including trust, empathy, and sensitive parenting. Although, recent research shows that the effects of oxytocin are more nuanced than previously thought (Bartz et al., 2011), a group of researchers has recently explored the potential of using ‘intranasal’ oxytocin, that is oxytocin that can be safely administered by the nose, to treat AN.

The study conducted in South Korea in collaboration with researchers in London, UK, found that intranasal oxytocin as compared to placebo led 31 women with AN to pay less attention to images of food and fatter body shapes. The researchers suggested that oxytocin may thus be able to reduce these patients usual, obsessional focus on eating and body shape. However, it is important to note that oxytocin had no effect on the amount of juice consumed in either the AN or the control group of the study. Moreover, before we can conclude that oxytocin can be used to treat AN, we will need different kind of studies to be conducted, in which oxytocin is administered for longer periods of time and food intake, weight, body image distortions and other relevant facets of AN are carefully studied.
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American Psychiatric Association (2013). Diagnostic and Statistical Manual of Mental Disorders (Fifth ed.). Arlington, VA: American Psychiatric Publishing

Kim Y, Kim C, Cardi V, et al. Intranasal oxytocin attenuates attentional bias for eating and fat shape stimuli in patients with anorexia nervosa. Psychoneuroendocrinology, Volume 44, June 2014, Pages 133-142.

Bartz JA, Zaki J, Bolger N, Ochsner KN. Social effects of oxytocin in humans: context and
person matter. Trends Cogn Sci 2011; 15:301–9.

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Why can body dissatisfaction have such a harmful effect on our self-esteem?

We have already seen a strong link between self-esteem and body image. But not only does self-esteem impact body image, body image also has an effect on self-esteem. Body dissatisfaction and weight gain can lead to decreased self-esteem (Tiggemann, 2005). In addition, judging oneself to be overweight seems to be more of a self-esteem issue among women than men, and research has shown that women sometimes see losing weight as a strategy for improving their self-esteem (Bale & Archer, 2013; Furnham, Badmin & Sneade, 2002; Gentile et al., 2009).

Why are our body image and our self-esteem linked to this extent, and why does this link seem to be stronger for females than for males? This is obviously a complex question, but the answer has something to do with how we go about forming our self-esteem. One influential conceptualisation of self-esteem, known as the sociometer hypothesis, sees an individual’s self-esteem as the extent to which they perceive themselves to be included or excluded by others (Leary & Baumeister, 2000). Women in particular may see getting along in relationships with others as highly important to their sense of self-worth. And one important criteria on which individuals make such judgements is how physically attractive they think they are (Bale & Archer, 2013). Perhaps it is worth bearing in mind here that, on average, women believe that men prefer a female figure which is significantly thinner than the female figure that men actually tend to prefer! (Grossbard, Neighbors & Larimer, 2011)

On a more serious note, how can we try to protect against body dissatisfaction having such a harmful effect on our self-esteem? In the spirt of changing our minds and not our bodies, one answer could lie in trying to focus our self-esteem on aspects of ourselves other than our physical appearance – and this is in fact one of the strategies used by the ‘Everybody’s Different’ school project (see Message of the day: 13th January 2015).

 
Bale, C., & Archer, J. (2013). Self-Perceived Attractiveness, Romantic Desirability and Self-Esteem: A mating sociometer perspective. Evolutionary Psychology, 11(1), 68-84.
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Furnham, A., Badmin, N., & Sneade, I. (2002). Body image dissatisfaction: Gender differences in eating attitudes, self-esteem, and reasons for exercise.The Journal of psychology, 136(6), 581-596.

Gentile, B., Grabe, S., Dolan-Pascoe, B., Twenge, J. M., Wells, B. E., & Maitino, A. (2009). Gender differences in domain-specific self-esteem: A meta-analysis. Review of General Psychology, 13(1), 34.

Grossbard, J. R., Neighbors, C., & Larimer, M. E. (2011). Perceived Norms for Thinness and Muscularity among College Students: What Do Men and Women Really Want? Eating Behaviors, 12(3), 192–199.

Leary, M. R., & Baumeister, R. F. (2000). The nature and function of self-esteem: Sociometer theory. Advances in experimental social psychology, 32, 1-62.

Tiggemann, M. (2005). Body dissatisfaction and adolescent self-esteem: Prospective findings. Body image, 2(2), 129-135.

Common cosmetic surgery procedures such as breast augmentation (“boob jobs”) and rhinoplasty (“nose jobs”) have increased by more than 700% in the past 10 years (American Society of Plastic Surgeons, ASPS, 2003 *LINK to website*). One reason for this explosionmay relate to the increasing willingness of individuals to view these procedures as a way to combat dissatisfaction with their physical appearance. Body image has always been considered a key motivator in people’s decisions to undergo cosmetic surgery, but change in body image as a result of cosmetic surgery has only recently begun to be investigated ad the results are mixed.

Studies reporting positive effects have been criticised for using biased methods such as assessment by the surgeon themselves (Sarwer et al., 2002) and more rigorous research has been less favourable. For example, a postoperative investigation of 45 women undergoing facial cosmetic procedures did find that the degree of dissatisfaction with the target facial feature of surgery was improved, but not their overall body image (Sarwer et al., 2002

Source: Sarwar, D. B., & Crerand, C. E. (2004). Body image and cosmetic medical treatments. Body Image, 1, 99-111.

Source: Phillips, K. A., Grant, J., Siniscalchi, J., & Albertini, R. S. (2001). Surgical and nonpsychiatric medical treatment of patients with body dysmorphic disorder. Psychosomatics, 42, 504-510.
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Eating disorders such as anorexia and bulimia are widespread and have serious physical and psychological impacts on those affected. Their causes are complex and varied, but (unsurprisingly) concerns about body image have been identified as an important factor in these illnesses (Cooley & Toray, 2001). Unhealthy concerns about one’s physical appearance can lead to body avoidance, where a person dresses in baggy clothes for example, or avoids looking in the mirror; to excessive body checking, such as constantly and critically looking in mirrors; and / or being acutely aware of not matching the ideal body images constantly being portrayed in the media around us (and which most of us bear no resemblance to!).

The practice of Mindfulness promotes patterns in thinking which directly challenge the unhelpful behaviours described above. Mindfulness is a type of meditation which encourages the individual to direct their attention to whatever they are physically or emotionally experiencing in the present moment, in an accepting and non-judgemental way. Over time, an individual may become less critical of themselves – not constantly comparing themselves to others or ideals – and less preoccupied with scrutinising or avoiding the sight of their own body.

On this basis, Alberts, Thewissen and Raes (2012) hypothesised that increased levels of mindfulness would be likely to be associated with lower levels of concern over body image. A sample of 26 adult women were assessed for their baseline levels of mindfulness and body image concern, using standardised questionnaires. All women had reported some type of difficulty in their relationship with food or controlling their weight, but none were diagnosed as having a clinical eating disorder. Half of the women were then given an 8 week mindfulness training course, with daily exercises to promote awareness of their physical sensations and thoughts relating to eating, food and their bodies. At the end of the study, the women who underwent the training showed a significant increase in mindfulness, and a significant reduction in body image concern, relative to the control group.

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Cooley, E., & Toray, T. (2001). Body image and personality predictors of eating disorder symptoms during the college years. International Journal of Eating Disorders, 30, 28–36.

Alberts, H.J.E.M., Thewissen, R. and Raes, L. (2012). Dealing with problematic eating behaviour. The effects of a mindfulness-based intervention on eating behaviour, food cravings, dichotomous thinking and body image concern. Appetite, 58, 847-851.

Problem: Cultural expectations dictate that girls should be thin and boys should have muscular bodies. This ideal seems to be the source of body image concern in adolescent boys and girls, in a period of their lives when the importance of their appearance is heightened. Such concerns might lead to disordered eating, or to full-blown eating disorders later in their lives. One of the factors for this concern is appearance-related (negative) teasing by family members and friends. A recent study (Shaefer, & Salafia, 2014) showed that such teasing by the mother, father, the siblings and peers was significantly associated with body dissatisfaction in adolescent girls, and with higher drive for muscularity in boys; this was found for boys and girls of all shapes and sizes.

Solution: it is important that clinicians become aware of the influence that appearance-related teasing has on young persons. Intervention programs and therapists, for example, when working with adolescents, should include all family members, investigate how they contribute to the adolescent’s body image, and educate them about the effect of teasing.
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For more information: Schaefer, M. K., & Salafia, E. H. B. (2014). The connection of teasing by parents, siblings, and peers with girls’ body dissatisfaction and boys’ drive for muscularity: The role of social comparison as a mediator. Eating behaviors, 15(4), 599-608.

Most of us know the feeling of being dissatisfied about certain parts of our bodies, be it that we think our thighs are too fat, our bums too big etc. But as our campaign hopes to demonstrate, we can change our minds to help us feel more positive about our bodies. One way, as we saw here (Message of the day: 16th January 2015) is to challenge beauty norms. Today’s message focuses on how we can also improve our own perception of ourselves.

We have already heard that boosting self-esteem, by improving our general evaluation of ourselves, can improve body satisfaction (see Message of the day: 13th January 2015). But what about going a step further to focus specifically on being kind to ourselves? Being understanding and non-judgmental of our shortcomings is captured by a psychological construct termed self-compassion. Higher self-compassion is linked to being more accepting of ourselves. Might higher levels of self-compassion be connected to higher body satisfaction as well?

Researchers in Canada found that self-compassion was indeed related to women’s concerns about their bodies. Across two studies, they demonstrated that women scoring higher on a measure of self-compassion – and especially on items relating to how judgmental they were of themselves – had fewer concerns about their bodies. This was found even when controlling for women’s levels of self-esteem, indicating that there may be a unique benefit in being kind to ourselves. Although this study assessed the degree of self-compassion women generally had already, rather than boosting their self-compassion in the study, do give it a try: Be kind to yourself, and change your mind, not your body!
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Reference: Wasylkiw, L., MacKinnon, A. L., & MacLellan, A. M. (2012). Exploring the link between self-compassion and body image in university women. Body Image, 9, 236-245.

Could the use of more plus size models change women’s obsession with thin bodies?

We live in a society where, though the media, we are surrounded by models and celebrities who are super-slim and as a result there is a general climate of obsession with thin bodies. The question is:

Will people’s attitudes towards body image change if there is more diversity in the body shapes and sizes portrayed in the media?

Researchers from Durham University, Newcastle University and VU University Amsterdam studied more than 100 women and found that women who habitually preferred thin models were significantly less keen on thin bodies after being presented with plus-size models. On the other hand, when women were shown images of thin models, their preference shifted even more towards thinness. In addition, positive and negative associations with weight were explored. When women were presented with aspirational images of plus-size models, paired with plain images of underweight women, their preferences shifted away from thinness.
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The findings suggest that using plus size models can indeed rebalance our attitudes about what is considered to be beautiful and healthy and decrease the obsession with being super-slim. ‘Normalising’ female models in the media could be a first essential step towards changing our minds instead of our bodies and feel happier and more satisfied with the way we look!

For more information: Boothroyd, L.G., Tovée, M.T. & Pollett, T. (2012). Visual Diet versus Associative Learning as Mechanisms of Change in Body Size Preferences. PLoS ONE 7(11)