Background: although cognitive behavioural therapy is the gold standard treatments for bulimia nervosa (BN) and binge eating disorder (BED), evidence for its long-term efficacy is weak. Empirical research support the efficacy of brief strategic therapy (BST) in treating BN and BED symptoms, but its statistical significance still need to be investigated. Objective: to statistically test the long-term efficacy of the BST treatment protocols for BN and BED through one-year post-treatment. Methods: a two-group longitudinal study will be conducted. Participants (...) will be sequentially recruited for inclusion in a state-funded community psychotherapy clinic. Multilevel growth curve modeling will be used to estimate the average growth trajectories from baseline to one year after treatment termination for the severity of the BN and BED features as measured by the Eating Disorder Examination Questionnaire. Discussion: findings from this study will clarify the impact of BST in treating BN and BED symtoms. Conclusions: translating research into practice may inform how to ensure high-quality patient care. (shrink)

A distorted representation of one's own body is a diagnostic criterion and core psychopathology of both anorexia nervosa (AN) and bulimia nervosa (BN). Despite recent technical advances in research, it is still unknown whether this body image disturbance is characterized by body dissatisfaction and a low ideal weight and/or includes a distorted perception or processing of body size. In this article, we provide an update and meta-analysis of 42 articles summarizing measures and results for body size estimation (...) (BSE) from 926 individuals with AN, 536 individuals with BN and 1920 controls. We replicate findings that individuals with AN and BN overestimate their body size as compared to controls (ES= 0.63). Our meta-regression shows that metric methods (BSE by direct or indirect spatial measures) yield larger effect sizes than depictive methods (BSE by evaluating distorted pictures), and that effect sizes are larger for patients with BN than for patients with AN. To interpret these results, we suggest a revised theoretical framework for BSE that accounts for differences between depictive and metric BSE methods regarding the underlying body representations (conceptual vs. perceptual, implicit vs. explicit). We also discuss clinical implications and argue for the importance of multimethod approaches to investigate body image disturbance. (shrink)

Understanding Eating Disorders is an original contribution to the field of healthcare ethics. It develops a new theory concerning the moral basis of eating disorders, and places such disorders for the first time at the centre of philosophical discourse. The book explores the relationship that people have with food and their own body by looking at genetics and neuro-physiology, sociology and family studies, clinical psychology and psychiatry, and frames abnormal eating at the extreme of a spectrum of normal behaviours, directed (...) by moral values. Giordano argues that abnormal eating is not a psycho-pathological phenomenon, but the coherent implementation of ordinary moral values with a long tradition in Western culture. The book also contains a detailed analysis of UK legislation, accompanied by a timely critique of the law on treatment of mental disorders in general and of eating disorders in particular. (shrink)

This study investigated the relationship between disorders of the body self and personality defence mechanisms of women with bulimia nervosa. It was hypothesized that women with bulimia nervosa would not form a homogeneous group in terms of the body self disorder and that the extent of this disorder would be significantly related to personality functioning in terms of the defence styles adopted. The hypothesis was investigated with the aid of two questionnaires: the Body Self Questionnaire and (...) the Defence Style Questionnaire by Andrews, Singh and Bond. 36 women aged between 15 and 25 years, who fulfilled the DSM IV criteria for bulimia nervosa participated in the study. Conclusions from the study were that: the body self of bulimic women is differentially disordered at three levels: profound, moderate and minimal. the degree to which the body self was found to be disordered is significant in psychological terms as it is related to the defence style adopted by the bulimic personality. The profound and moderate levels of body self disorder related to immature defence styles, while minimal levels of disruption to body self were associated with neurotic and mature styles. (shrink)

ObjectiveBulimia nervosa and binge eating disorder are eating disorders characterized by recurrent binge eating episodes. Overlap exists between ED diagnostic groups, with BE episodes presenting one clinical feature that occurs transdiagnostically. Neuroimaging of the responses of those with BN and BED to disorder-specific stimuli, such as food, is not extensively investigated. Furthermore, to our knowledge, there have been no previous published studies examining the neural response of individuals currently experiencing binge eating, to low energy foods. Our objective was to (...) examine the neural responses to both low energy and high energy food images in three emotive categories in BN and BED participants.MethodsNineteen females with BN or BED, comprising the binge eating group, and 19 age-matched healthy control ’s completed thorough clinical assessment prior to functional MRI. Neural response to low energy and high energy foods and non-food images was compared between groups using whole-brain exploratory analyses, from which six regions of interest were then selected: frontal, occipital, temporal, and parietal lobes; insula and cingulate.ResultsIn response to low energy food images, the BEG demonstrated differential neural responses to all three low energy foods categories compared to HCs. Correlational analyses found a significant association between frequency of binge episodes and diminished temporal lobe and greater occipital lobe response. In response to high energy food images, compared to HC’s, the BEG demonstrated significantly decreased neural activity in response to all high energy food images. The HC’s had significantly greater neural activity in the limbic system, occipital lobe, temporal lobe, frontal lobe, and limbic system in response to high energy food images.ConclusionResults in the low energy food condition indicate that binge frequency may be related to increased aberrant neural responding. Furthermore, differences were found between groups in all ROI’s except the insula. The neural response seen in the BEG to disgust food images may indicate disengagement with this particular stimuli. In the high energy food condition, results demonstrate that neural activity in BN and BED patients may decrease in response to high energy foods, suggesting disengagement with foods that may be more consistent with those consumed during a binge eating episode. (shrink)

The current study is aimed at creating a psychological profile of characteristics of aggressive and self-aggressive behaviour exhibited by females with bulimia, as well as conducting a comparative analysis of the differences between bulimic females and individuals displaying no mental disorders in terms of the major characteristics of aggressive and selfaggressive behaviour. The methods: the Buss-Durkee Hostility-Guilt Inventory, the Psychological Inventory of Aggression Syndrome by Zbigniew. B. Gaś. The data analysis revealed significant differences between the females suffering from (...) class='Hi'>bulimia and the subjects displaying no mental disorders in terms of the level of aggressive and self-aggressive tendencies. It was discovered that the control participants exhibited an appropriate level of aggressive behaviour as opposed to the subjects with bulimia. (shrink)

Understanding Eating Disorders endeavors to answer the question “How should we behave when dealing with a person with eating disorders?” (254). In the pursuit of this question, Giordano undertakes two primary tasks. First, she constructs an analysis of eating disorders that attempts to show why they should be understood “from a moral perspective. Eating disorders signify a person’s belonging and adherence to a determined moral context” (8). Second, she conducts an exploration of autonomy, and asks whether it is justified to (...) regard persons with mental illnesses in general, and persons with eating disorders in particular, as lacking autonomy, and thus as candidates for paternalistic treatment—force feeding, for instance. (shrink)

Anorexia nervosa involves seemingly irrational beliefs about body size and the value of thinness. Historically, researchers and clinicians have avoided referring to such beliefs as delusions, instead opting for the label ‘overvalued ideas’. I discuss the relationship between the beliefs associated with anorexia nervosa and the distinction between delusions and overvalued ideas, as it is conceived in both European and American psychiatric traditions. In doing so, I question the benefit of applying the concepts of delusion and overvalued idea (...) to anorexia nervosa and raise some issues with contemporary use of the Brown Assessment of Beliefs scale for assessing the level of delusionality associated with the disorder. (shrink)

OBJECTIVE: This paper addresses the question of the circumstances which lead clinicians to use legal coercion in the management of patients with severe anorexia nervosa, and explores similarities and differences between such formal coercion and other forms of 'strong persuasion' in patient management. METHOD: Logistic regression and other statistical analysis was undertaken on 75 first admissions for anorexia nervosa from a sample of 117 successive admissions to an eating disorder facility in New South Wales, Australia, where an eating (...) disorder was the primary diagnosis. Admissions with other primary diagnoses, such as bulimia nervosa (25 episodes), and entries with a co morbid diagnosis (e.g. depression or opiate overdose), were discarded, leaving 96 admissions by 75 individuals. RESULTS: Resort to measures of legal coercion into treatment was found to be associated with three main indicators: the patient's past history (number of previous admissions); the complexity of their condition (the number of other psychiatric co morbidities); and their current health risk (measured either by Body Mass Index or the risk of re-feeding syndrome). CONCLUSIONS: Our study is consistent with the few earlier studies about indicators for legal coercion in anorexia nervosa management, and suggests that clinicians use legal coercion very sparingly, distinguishing legal coercion from other forms of close clinical management of patients. (shrink)

Previous research has shown that short-term fasting in healthy individuals is associated with changes in risky decision-making. The current experiment was designed to examine the influence of short-term fasting in healthy individuals on four types of impulsivity: reflection impulsivity, risky decision-making, delay aversion, and action inhibition. Participants were tested twice, once when fasted for 20 hours, and once when satiated. Participants demonstrated impaired action inhibition when fasted; committing significantly more errors of commission during a food-related Affective Shifting Task. Participants also (...) displayed decreased reflection impulsivity when fasted, opening significantly more boxes during the Information Sampling Task (IST). There were no significant differences in performance between fasted and satiated sessions for risky decision-making or delay aversion. These findings may have implications for understanding eating disorders such as Bulimia Nervosa (BN). Although BN has been characterised as a disorder of poor impulse control, inconsistent findings when comparing individuals with BN and healthy individuals on behavioural measures of impulsivity question this characterisation. Since individuals with BN undergo periods of short-term fasting, the inconsistent findings could be due to differences in the levels of satiation of participants. The current results indicate that fasting can affect performance on the IST, a measure of impulsivity previously studied in BN, whilst performance on other impulsivity measures were unaffected. However, the results from the IST were contrary to the original hypothesis and should be replicated before specific conclusions can be made. (shrink)

Qualitative inquiry into eating disorders is burgeoning, offering valuable and innovative insights into various aspects of the condition. This study used life‐history interviews with 20 women who had recovered from anorexia nervosa, bulimia nervosa or both and who had remained healthy. The interviews focused on the women's narratives and experience rather than a diagnostic therapeutic model. Three themes of control, connectedness and conflict emerged as significant in the development, experience of, and recovery from an eating disorder. The (...) development of the condition was attributed to a lack of control, a sense of non‐connectedness to family and peers and extreme conflict with significant others. Recovery occurred when the women re‐engaged with life, developed skills necessary for conflict resolution and rediscovered their sense of self. Rather than viewing the development of, and recovery from an eating disorder as separate and discrete events, the data from the life‐history interviews suggest they are better viewed as one entity — that is, the journey of an individual attempting to discover and develop their sense of self. This perspective challenges some current constructs of eating disorders; it is not a condition in and of itself but a symptom of deeper issues that if addressed, when the individual is ‘ready’ to make that choice, will lead to recovery. (shrink)

Introduction. Eating Disorders (EDs) are serious psychiatric disorders, impacting physical and psychosocial functioning, often with a chronic course and high mortality rates. The two continua model of mental health states that mental health is a complete state, that is not merely the absence of mental illness, but also the presence of mental health. This model was studied among ED patients by comparing the levels of well-being to the Dutch general population and by examining the of well-being and psychopathology. Method. A (...) total of 468 female ED patients participated in this study during application and intake at a specialized ED treatment centre in the Netherlands. They filled out questionnaires about well-being (MHC-SF), general psychopathology (OQ-45), and ED psychopathology (EDE-Q). Categorical and mean well-being levels were calculated. Also, the correlates of these variables were examined with Pearson correlation and multiple hierarchical regression analysis. Results. ED patients showed lower levels of emotional, psychological and social well-being on average compared to the general population. About 26% of the ED patients experienced low levels of well-being (languishing). However, also 13% experienced high levels of well-being (flourishing), varying between 9% in Anorexia Nervosa to 25% in Binge Eating Disorder. ED psychopathology and general well-being showed a moderate negative correlation. For patients with Bulimia Nervosa and Binge Eating Disorder however no such correlation was found. Lower general psychopathology, not having a history of hospitalization for the ED, and adaptive personal functioning were correlated with well-being among ED patients. Conclusion This study shows initial support for the two continua model of mental health among ED patients. Psychopathology and well-being should be considered as related, but distinct dimensions of mental health in ED patients. Further research should focus on the possible reciprocal relationships between psychopathology and well-being during recovery. It is recommended to monitor well-being during treatment and to implement interventions for well-being to realize complete recovery for those patients with inadequate levels of well-being. (shrink)

Eating disorders are evolutionarily novel conditions that lead to some of the highest mortality rates of all psychiatric disorders. Several evolutionary hypotheses have been proposed for eating disorders, but only the intrasexual competition hypothesis is extensively supported by evidence. We present the mismatch hypothesis as a necessary extension to the current theoretical framework of eating disorders. This hypothesis explains the evolutionarily novel adaptive metaproblem that has arisen when mating motives and readily available food rewards conflict with one another. This situation (...) is exacerbated in contemporary environments characterized by sedentary lifestyles, caloric surplus and the ubiquity of social comparisons that take place via social media. Our psychoneuroimmunological model connects ultimate-level causation with proximate mechanisms by showing how the adaptive metaproblem between mating motives and food rewards leads to chronic stress and, further, to disordered eating. Chronic stress causes neuroinflammation, which increases susceptibility to OCD-like behaviors that typically co-occur with eating disorders. Chronic stress upregulates the serotonergic system and causes dysphoric mood in patients with restricting-type anorexia nervosa. Dieting, however, reduces serotonin levels and dysphoric mood, leading to a vicious serotonergic-homeostatic stress/starvation cycle whereby cortisol and neuroinflammation increase through stringent dieting. Between-individual and within-individual variation in eating disorders partially arises from (co)variation in gut microbiota and stress responsivity, which influence neuroinflammation and the serotonergic system. In binge-related eating disorders, even a short period of fasting drops serotonin levels, a state alleviated by binge eating. Eating disorder treatments should aim to reduce the chronic stress, neuroinflammation, stress responsivity and gut dysbiosis that fuel the disorders. We review the advances that have been made in recent years in understanding how to best treat eating disorders, outlining directions for future clinical research. Connecting ultimate causes with proximate mechanisms and treating biopsychosocial causes rather than manifest symptoms will enable more effective and sophisticated long-term interventions for the millions of people who suffer from eating disorders. (shrink)

I propound a mechanistic theory of natural kinds in the human sciences. By examining a culture- bound psychiatric disorder, bulimia nervosa, I illustrate how partially socially constructed phenomena raise a serious challenge to traditional theories of natural kinds. As a solution to the challenge, I show how the mechanistic approach allows us to include real but partly socially sustained phenomena among natural kinds. This is desirable because the theory of natural kinds supplies the human sciences with a clear (...) normative account of concept formation. Furthermore, my theory suggests a conceptual framework for interdisciplinary research on complex phenomena. As a prerequisite for the mechanistic approach, the concept of natural kind in the philosophy of science must be distinguished from the use of the notion in other parts of philosophy. (shrink)

Eating disorders (EDs) are characterized by marked cognitive distortions and maladaptive schemas. Cognitive models of EDs highlight the direct impact of cognitive dysfunctions on eating-related disturbances, insofar as specific cognitive contents such as thoughts about diet rules and food or loss of control may trigger disturbed eating behavior. Moreover, early maladaptive schemas that reflect perfectionist standards and relate to achievement and performance seem to be associated with disturbed eating, e.g. via their impact on situation-specific appraisals. However, so far, no study (...) has investigated these assumptions. Hence, the present study sought to demonstrate whether and how cognitive content exerts an impact on eating behavior in daily life, and whether maladaptive core schemas impact the occurrence of binge eating via dysfunctional ED cognitions in eating-related contexts. N = 29 females with Bulimia Nervosa (BN), n = 31 females with Binge Eating Disorder (BED) and n = 30 female controls without EDs (NC) participated in the study. All participants received a handheld computer for a 48-hour period to capture antecedents of disturbed eating behavior in daily life. Event-sampling (meals, binge eating, purging, stressful situations) and signal-sampling (five times a day) methods were applied. EMA included a short questionnaire to assess dysfunctional cognitions and level of craving and to capture information about situational contexts. Early maladaptive schemas were assessed using a short version of the Young Schema Questionnaire at baseline. The main results showed specific patterns of dysfunctional eating-related cognitions for BED and BN. Binge eating was predicted by thoughts about loss of control (positively) and dietary restraint (negatively). For meal situations, no significant differences between the two ED groups emerged. All three domains exerted indirect effects on craving via thoughts about ‘eating/loss of control’, whereas neither a direct nor an indirect effect emerged regarding thoughts about ‘dietary restraint’. These results fit well with previous studies and support cognitive models of EDs; schema therapeutic approaches may be a valuable contribution to enhance treatment of EDs. Further studies should explore whether the findings from emerging adulthood can be generalized to younger age groups. (shrink)

Sufferers of eating disorders often hold false beliefs about their own body size. Such beliefs appear to violate norms of rationality, being neither grounded by nor responsive to appropriate forms of evidence. I defend the rationality of these beliefs. I argue that they are in fact supported by appropriate evidence, emanating from proprioceptive misperception of bodily boundaries. This argument has far‐reaching implications for the explanation and treatment of eating disorders, as well as debates over the relationship between rationality and human (...) psychology. (shrink)

Many who suffer from eating disorders claim that they see themselves as “fat”. Despite decades of research into the phenomenon, behavioural evidence has failed to confirm that eating disorders involve visual misperception of own-body size. I illustrate the importance of this phenomenon for our understanding of perceptual processing, outline the challenges involved in experimentally confirming it, and provide solutions to those challenges.

This paper discusses the findings of qualitative research that examined the accounts of five “mostly recovered” ex-patients who had experienced transition between two or more eating disorder diagnoses. This study found that, in the minds of participants, the different diagnostic labels were associated with various good or bad character traits. This contributed to the belief in a diagnostic hierarchy, whereby individuals diagnosed with anorexia nervosa were viewed as morally better than those diagnosed with bulimia nervosa or binge (...) eating disorder. Consequently, diagnostic crossover from a “better” to a “worse” eating disorder was often experienced as shameful moral failing, and a new diagnosis impacted the individual’s sense of self-identity. These findings are of significance for both ethicists and clinicians; the paper concludes by outlining the relevance and possible clinical implications of shame in diagnostic crossover and suggesting avenues for future research. (shrink)

BackgroundOther Specified Feeding and Eating Disorders are characterized by less frequent symptoms or symptoms that do not meet full criteria for another eating disorder. Despite its high prevalence, limited research has examined differences in severity and treatment outcome among patients with OSFED compared to threshold EDs [Anorexia Nervosa, Bulimia Nervosa, and Binge Eating Disorder ]. The purpose of the current study was to examine differences in clinical presentation and treatment outcome between a heterogenous group of patients with (...) OSFED or threshold EDs.MethodPatients with threshold EDs or OSFED presenting for eating disorder treatment completed self-report questionnaires at intake and discharge to assess eating disorder symptoms, depression symptoms, impairment, and self-esteem.ResultsAt intake, OSFED patients showed lower eating concerns compared to patients with BN, but similar levels compared to AN and BED. The OSFED group showed higher restraint symptoms compared to BED, and similar restraint to AN and BN. Global symptoms as well as shape and weight concerns were similar between OSFED and threshold ED groups. There were no differences between diagnostic groups in self-esteem, depression scores, or symptom change from intake to discharge.DiscussionOur findings suggest that individuals with OSFED showed largely similar ED psychopathology and similar decreases in symptoms across treatment as individuals diagnosed with threshold EDs. Taken together, findings challenge the idea that OSFED is less severe and more resistant to treatment than threshold EDs. (shrink)

Binge-purge eating disorders, such as bulimia nervosa and binge eating disorder, may share some neurobiological features. Electroencephalography is a non-invasive measurement modality that may aid in research and diagnosis of BP-ED. We conducted a systematic review of the literature on EEG findings in BP-ED, seeking to summarize and analyze the current evidence, as well as identify shortcomings and gaps to inform new perspectives for future studies. Following PRISMA Statement recommendations, the PubMed, Embase, and Web of Science databases were (...) searched using terms related to “electroencephalography” and “binge-purge” eating disorders. Of 555 articles retrieved, 15 met predefined inclusion criteria and were included for full-text analysis. Eleven studies investigated EEG by means of event-related potentials in BP-ED individuals: 7 using eating disorder-related stimuli and 4 using non-eating disorder-related stimuli. These studies found significant differences in the N200, P200, P300, and LPP components in BP-ED participants compared to controls, indicating that this population exhibits impairments in selective attention, attentional allocation/processing, and allocation of motivational or emotion-based attention. Five studies investigated EEG using frequency analysis; reporting significant differences in beta activity in fronto-temporal and occipito-temporo-parietal areas in BP-ED individuals compared to controls, revealing a dysfunctional brain network. However, the small number of studies, the heterogeneity of samples, study paradigms, stimulus types, and the lack of an adequate assessment of neuropsychological parameters are some limitations of the current literature. Although some EEG data are promising and consistent with neuroimaging and neuropsychological findings in individuals with BP-ED, future studies need to overcome current methodological shortcomings. (shrink)

Simona Giordano presents the first full philosophical study of ethical issues in the treatment of anorexia and bulimia nervosa. Beginning with a comprehensive analysis of these conditions and an exploration of their complex causes, she then proceeds to address legal and ethical dilemmas such as a patient's refusal of life-saving treatment. Illustrated with many case-studies, Understanding Eating Disorders is an essential tool for anyone working with sufferers of these much misunderstood conditions, and for all those ethicists, lawyers, and (...) medical practitioners engaged with the widely relevant issues they raise. (shrink)

This article reintroduces a phenomenological experiment designed in the early 1960’s, The Alien-Hand Experiment (TAHE), and it illustrates how phenomena denoted by theoretical concepts like body image, body schema and agency can be studied via the experiment. An analysis of the verbal reports from 26 subjects who participated in TAHE is presented in this article. Subjects were divided into three groups: A group of non-bulimic men, a group of non-bulimic women and a group of female bulimics. The group of (female) (...) bulimics was studied due to the widely spread notion that subjects suffering from eating disorders have a distorted body image. TAHE can be thought of as both a qualitative and quantitative way to study the phenomena arising when the normal relationship between motor behaviour and body experience is disrupted. The present investigation is not an operational definition of body schema and body image, but the two concepts offer a useful interpretive framework. (shrink)

This chapter examines so-called body image disorders, focusing on body dysmorphic disorder, anorexia nervosa, bulimia nervosa, and binge eating disorder. These disorders have been studied extensively by psychologists and psychiatrists from both the "body image" and "body shame" research orientations. Body image disorders have also proved, for feminist thinkers mindful of the gender imbalance in many of these disorders, to be an important locus for cultural criticism, including criticism of psychological and psychiatric perspectives. Those philosophers and anthropologists (...) with a phenomenological bent, particularly those with an interest in the lived body and embodiment, have also found a fruitful terrain in body image disorders. These different disciplines and approaches provide multiple perspectives which are often complementary, occasionally in some tension with one another, but always mutually enriching, and all of them are sketched here. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Eating Disorders and Mimetic Desire René Girard Stanford University Among younger women, eating disorders are reaching epidemic proportions. The most widespread and spectacular at this moment is the most recently identified, the so-called bulimia nervosa, characterized by binge eating followed by "purging," sometimes through laxatives or diuretics, more often through self-induced vomiting. Some researchers claim that, in American colleges, at least one third of the female student (...) population is involved to some degree. (Since nine out of ten sufferers are women I will use feminine pronouns in this paper but some undergraduates at Stanford tell me that the epidemic is spreading to male students.) G.M.F. Russell, the first researcher who focused on the specific aspects ofmodern bulimia, is usually presented as the discoverer of a new illness. The title ofhis 1979 publication contradicts this view: "Bulimia Nervosa: An Ominous Variant ofAnorexiaNervosa." And, indeed, all the symptoms he describes had been mentioned before in connection with anorexia (see Bruch). The insurance companies and the medical profession like only welldefined illnesses, and so does the public. We all try to distance ourselves from pathological contamination by giving it a name. Eating disorders are often discussed as ifthey were new varieties ofmeasles or oftyphoid fever. Why distrust the distinction between two illnesses with symptoms as radically opposed as those of anorexia and bulimia? Because we live in a world where eating too much and not eating enough are opposite but inseparable ways ofcoping with the slenderness imperative that dominates 2 René Girard our collective imaginations. Most of us oscillate all our lives between attenuated forms ofthese two pathologies. The man in the street understands perfectly a truth that most specialists prefer not to confront. Our eating disorders are caused by our compulsive desire to lose weight. Most books on the subject acknowledge the universal calorie phobia but somewhat absent-mindedly, as if it could not be the major cause ofa serious illness. How could a fundamentally healthy desire become the cause ofpathological behavior, even ofdeath? Many people would be healthier, no doubt, ifthey ate less. In view of this fact, it is not illogical to suppose that, in anorexia, there must be some motivation other than this healthy desire, some unconscious drive, no doubt, that generates abnormal behavior. By turning anorexia and bulimia into two separate pathologies, the classificators make it easier for us to lose sight of their common basis. The bankruptcy of modern theories The search for hidden motivations is the alpha and omega, ofcourse, of our modern culture. Our number one principle is that no human phenomenon is really what it seems to be. A satisfactory interpretation must rely on one of the hermeneutics of suspicion that have become popular in the nineteenth and twentieth century, or on several ofthese, on a cocktail of soupçon: psychoanalysis, Marxism, feminism, etc. We automatically assume that social phenomena have little if anything to do with what is obvious in them, in this case the rejection offood. In anorexia, psychoanalysts usually diagnose "a refusal of normal sexuality," due to the patient's excessive desire "to please her father," etc. These explanations are still invoked in books being written right now but the voice is growing fainter. Around this sort of thing the smell of mustiness is overpowering. Even in Lacan's own land, the old arrogance is gone. Early in my life, I had an opportunity to observe that the eating practices ofyoung women have nothing to do with a desire to please their fathers. Just before World War II, a pretty cousin of mine was dieting furiously and her father, my uncle, was storming about helplessly, trying to get her to eat more. Fathers, as a rule, are not pleased to see their daughters starve themselves. This particular father was also a physician, at a time when the medical profession had not yet caught the disease it was already trying to cure. Eating Disorders andMimetic Desire3 This uncle was our family doctor and, as such, had great prestige in my eyes, at least until that day. I had not yet read Freud but my later skepticism regarding his conception offatherhood may well originate in this incident. I immediately... (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Eating Disorders and Mimetic Desire René Girard Stanford University Among younger women, eating disorders are reaching epidemic proportions. The most widespread and spectacular at this moment is the most recently identified, the so-called bulimia nervosa, characterized by binge eating followed by "purging," sometimes through laxatives or diuretics, more often through self-induced vomiting. Some researchers claim that, in American colleges, at least one third of the female student (...) population is involved to some degree. (Since nine out of ten sufferers are women I will use feminine pronouns in this paper but some undergraduates at Stanford tell me that the epidemic is spreading to male students.) G.M.F. Russell, the first researcher who focused on the specific aspects ofmodern bulimia, is usually presented as the discoverer of a new illness. The title ofhis 1979 publication contradicts this view: "Bulimia Nervosa: An Ominous Variant ofAnorexiaNervosa." And, indeed, all the symptoms he describes had been mentioned before in connection with anorexia (see Bruch). The insurance companies and the medical profession like only welldefined illnesses, and so does the public. We all try to distance ourselves from pathological contamination by giving it a name. Eating disorders are often discussed as ifthey were new varieties ofmeasles or oftyphoid fever. Why distrust the distinction between two illnesses with symptoms as radically opposed as those of anorexia and bulimia? Because we live in a world where eating too much and not eating enough are opposite but inseparable ways ofcoping with the slenderness imperative that dominates 2 René Girard our collective imaginations. Most of us oscillate all our lives between attenuated forms ofthese two pathologies. The man in the street understands perfectly a truth that most specialists prefer not to confront. Our eating disorders are caused by our compulsive desire to lose weight. Most books on the subject acknowledge the universal calorie phobia but somewhat absent-mindedly, as if it could not be the major cause ofa serious illness. How could a fundamentally healthy desire become the cause ofpathological behavior, even ofdeath? Many people would be healthier, no doubt, ifthey ate less. In view of this fact, it is not illogical to suppose that, in anorexia, there must be some motivation other than this healthy desire, some unconscious drive, no doubt, that generates abnormal behavior. By turning anorexia and bulimia into two separate pathologies, the classificators make it easier for us to lose sight of their common basis. The bankruptcy of modern theories The search for hidden motivations is the alpha and omega, ofcourse, of our modern culture. Our number one principle is that no human phenomenon is really what it seems to be. A satisfactory interpretation must rely on one of the hermeneutics of suspicion that have become popular in the nineteenth and twentieth century, or on several ofthese, on a cocktail of soupçon: psychoanalysis, Marxism, feminism, etc. We automatically assume that social phenomena have little if anything to do with what is obvious in them, in this case the rejection offood. In anorexia, psychoanalysts usually diagnose "a refusal of normal sexuality," due to the patient's excessive desire "to please her father," etc. These explanations are still invoked in books being written right now but the voice is growing fainter. Around this sort of thing the smell of mustiness is overpowering. Even in Lacan's own land, the old arrogance is gone. Early in my life, I had an opportunity to observe that the eating practices ofyoung women have nothing to do with a desire to please their fathers. Just before World War II, a pretty cousin of mine was dieting furiously and her father, my uncle, was storming about helplessly, trying to get her to eat more. Fathers, as a rule, are not pleased to see their daughters starve themselves. This particular father was also a physician, at a time when the medical profession had not yet caught the disease it was already trying to cure. Eating Disorders andMimetic Desire3 This uncle was our family doctor and, as such, had great prestige in my eyes, at least until that day. I had not yet read Freud but my later skepticism regarding his conception offatherhood may well originate in this incident. I immediately... (shrink)

Background: Greater vulnerability to negative emotions appears associated with the development and maintenance of eating disorders. A systematic review of psychophysiological studies using emotion-eliciting film clips reveals that there are no studies examining the effect of standardized validated film clips on psychophysiological response across a range of EDs.Methods: Using standardized validated film clips without ED-specific content, the present study examined self-reported emotions and psychophysiological responses of women with Binge-Eating Disorder, Anorexia Nervosa, Bulimia Nervosa, and Healthy Controls at (...) Baseline, during Neutral, Sad, Happy, and Fear-inducing film clips, and at Recovery.Results: Throughout the protocol, the ED groups reported significantly greater sadness and anxiety than HCs. Additionally, the AN group reported more fear, the BED group more frustration, and the BED and BN groups more tension than HCs. Compared to HCs, the BED group reported stronger urges to binge throughout the protocol, whereas BN group reported stronger urges to binge relative to the HC group only at Baseline and Recovery. The BN and BED groups experienced decreased urges to binge during all film clips compared to Baseline. Respiratory Sinus Arrhythmia levels were significantly lower in the BED group compared to HCs and the BN group throughout the protocol.Discussion: Standardized validated film clips can be used to elicit expected self-reported emotion and skin conductance responses in ED groups, although individuals with EDs compared HCs report greater negative emotions. Interestingly, film clips appeared to reduce urges to binge in binge-eating groups. (shrink)

In this article, I argue that various epistemic challenges associated with eating disorders (EDs) can negatively affect the care of already marginalized patient groups with various EDs. I will first outline deficiencies in our understanding of EDs—in research, healthcare settings, and beyond. I will then illustrate with examples cases where discriminatory misconceptions about what EDs are, the presentation and treatment of EDs, and who gets EDs, instantiate obstacles for the treatment of various ED patient groups.

Within a relatively brief period of time, there has been a veritable outpouring of research on anorexia nervosa and bulimia nervosa. This article presents a concise overview of some of the major works on these eating disorders from a variety of disciplines including biomedicine, psychology, sociology, and history. The article establishes a general context of Americans' preoccupation with food and diet. However, since the majority of those suffering from anorexia nervosa and bulimia nervosa are (...) female, this article places these eating disorders in the specific historical context of American women's history. In earlier times, some women reacted to their role expectations with physical responses. While linking modern phenomena to these earlier physical reactions of American women, the article also highlights the various twentieth-century social and cultural factors that push some modern girls and women to respond to their situations either by refusing food or consuming and regurgitating large quantities of food.In addition to the historical perspective, which points to the relevance of social and cultural factors as well as biomedical and psychological ones, the article offers an overview of the various theories currently suggested to explain the meaning of food to those who suffer from these disorders. These theories range from the addiction model to food as a metaphor for control and self-definition. Whatever the meaning of food, it is important to note that both anorexia nervosa and bulimia nervosa are determined by an interaction of many factors both personal and biological and social and cultural. (shrink)

Background: The literature has shown a significant association between traumatic experiences and eating psychopathology, showing a greater symptomatology in patients with trauma history. Less is known about the associations between trauma and cognitive schemas, and personality traits and the differences between childhood and adulthood trauma experiences. Thus, this paper aims to assess the clinical and psychological characteristics of eating disorder (ED) patients, looking for differences between patients without a history of trauma and patients with trauma experiences, as well as at (...) possible differences between exposure in childhood, adulthood, or repeated events. Another aim of the paper is to evaluate the possible mediation role of cognitive schemas and personality traits in the relationship between early trauma and eating psychopathology.Methods: From January to November 2020, 115 consecutive inpatients admitted for a specific multidisciplinary ED treatment in a dedicated Unit were evaluated for trauma, differentiating between trauma occurring in childhood and adulthood. The subjects were evaluated for early maladaptive schemas (EMS), personality traits, trauma symptomatology, quality of life, and specific psychopathologies linked to EDs. Mediation analyses between childhood and adulthood trauma and eating psychopathology were performed, with EMS and personality traits as mediators.Results: Patients with a history of trauma showed higher physical and psychological symptomatology scores, with a more impaired clinical profile in patients with both childhood and adulthood trauma exposure. The mediation analysis showed a specific mediator role for the “disconnection and rejection (DR)” EMS factor in the relationship between childhood trauma (cT) and eating psychopathology.Conclusion: Trauma experiences are associated with more severe clinical symptomatology in EDs and may need a specific assessment in patients with failed outpatient standard treatments. Specific cognitive schemas linked to DR domain should be evaluated in treatments for ED patients with history of trauma due to the mediation role between trauma and eating psychopathology. The need for outcome studies about treatment approaches for ED patients with history of trauma is discussed. (shrink)

Body Dissatisfaction The author concentrates on the preference of the values of "the cult of the body" increasingly affecting the behaviour of young people and their position in the value system relating to generally recognized values. Too much emphasis on physical beauty and outward appearance significantly determines behaviour and can lead to a reduction in values relating to the body and body shape but also to unhealthy eating disorders such as bulimia or anorexia nervosa. The focus is on (...) the pathological perception of the body, on how culture and cultural norms affect body dissatisfaction. A research questionnaire on universal values and the cult of the body (2006) was used. The research sample consisted of 508 respondents aged between 18 and 26 (292 women and 216 men). (shrink)

This is a preprint draft. Please cite published version (DOI: 10.1111/mila.12385). The aim of this paper is to provide a novel analysis of anorexia nervosa (AN) in the context of the sense of agency literature. I first show that two accounts of anorexia nervosa that we ought to take seriously— i.e., the first personal reports of those who have experienced it firsthand as well as the research that seeks to explain anorexic behavior from an empirical perspective— appear to (...) be thoroughly in tension with one another in their descriptions of anorexic actions. Rather than proceeding at this point by way of disregarding anorexic testimony as meaningless or insincere, I instead offer a positive account of the sense of agency in anorexia nervosa that renders these two depictions compatible. The resultant picture of anorexic behavior is one that accommodates current empirical findings while also providing valuable insight into how it is that anorexics can sincerely report feeling fully in control over their food restriction. (shrink)

Contemporary diagnostic criteria for anorexia nervosa explicitly refer to affective states of fear and anxiety regarding weight gain, as well as a fixed and very strong attachment to the pursuit of thinness as an overarching personal goal. Yet current treatments for that condition often have a decidedly cognitive orientation and the exact nature of the contribution of affective states and processes to anorexia nervosa remains largely uncharted theoretically. Taking our inspiration from the history of psychiatry, we argue that (...) conceptualizing anorexia nervosa as a passion is a promising way forward in both our understanding and treatment of that condition. Building on the theory of the passions elaborated by Théodule Ribot, the founder of scientific psychology in France, we argue that there is convincing empirical evidence in defense of the empirical hypothesis that anorexia nervosa is a passion in Ribot’s specific, technical sense. We then explore the implications of this finding for current approaches to treatment, including cognitive–behavioral therapy, and clinical and ethical issues associated with treatment refusals. (shrink)

Body dissatisfaction has long been considered an integral component of and driving force behind anorexia nervosa. In this paper, I characterise body dissatisfaction in terms of problematic beliefs about body size and the value of thinness. I suggest two methods for understanding these beliefs. Regarding body size beliefs, I suggest focusing on certain forms of misleading phenomenal evidence that sufferers of anorexia nervosa are exposed to. Regarding beliefs about the value of thinness, I suggest focusing on the benefits (...) of such beliefs. (shrink)

It feels like there’s two of you inside—like there’s another half of you, which is my anorexia, and then there’s the real K [own name], the real me, the logic part of me, and it’s a constant battle between the two. The anorexia almost does become part of you, and so in order to get it out of you I think you do have to kind of hurt you in the process. I think it’s almost inevitable. We came to the (...) concept of authenticity belatedly, one might say. We had been talking to people who had a diagnosis of anorexia nervosa about their experiences of living with their condition, and though we had not raised issues of authenticity or identity ourselves, they often did. They struggled with questions of .. (shrink)

Anorexia nervosa remains an enigma among Western cultures. Various causal explanations have been offered, encompassing biological, psychological, and sociocultural models. These explanations, however, focus on the immediate or proximal mechanisms of causation. A more thorough understanding of anorexia nervosa can be achieved by understanding the relationship between these factors and ultimate causation, the level of explanation which deals with individual reproductive fitness. This paper reviews the biological, psychological, sociocultural, and evolutionary models and indicates a necessary synthesis between proximate (...) and ultimate levels of causation in examining the anorexia nervosa puzzle. (shrink)

This paper argues that there is a relationship between understandings of anorexia nervosa (AN) and how the ethical issues associated with involuntary treatment for AN are identified, framed, and addressed. By positioning AN as a construct/discourse (hereinafter “AN: the diagnosis”) several ethical issues are revealed. Firstly, “AN: the diagnosis” influences how the autonomy and competence of persons diagnosed with AN are understood by decision-makers in the treatment environment. Secondly, “AN: the diagnosis” impacts on how treatment and treatment efficacy are (...) defined and the ethical justifiability of paternalism. Thirdly, “AN: the diagnosis” can limit the opportunity for persons with AN to construct an identity that casts them as a competent person. “AN: the diagnosis” can thus inherently affirm professional knowledge and values. Postmodern professional ethics can support professionals in managing these issues by highlighting the importance of taking responsibility for professional knowledge, values, and power and embracing moral uncertainty. (shrink)

Body checking, characterized by the repeated visual or physical inspection of particular parts of one’s own body (e.g. thighs, waist, or upper arms) is one of the most prominent behaviors associated with eating disorders, particularly Anorexia Nervosa (AN). In this paper, we explore the explanatory potential of the Recalcitrant Fear Model of AN (RFM) in relation to body checking. We argue that RFM, when combined with certain plausible auxiliary hypotheses about the cognitive and epistemic roles of emotions, is able (...) to explain key characteristics of body checking, including how body checking behavior becomes habitual and compulsive. (shrink)

This article will explore whether the law should allow people with anorexia nervosa to refuse nutrition and hydration with special reference to the English decision in Re E (Medical Treatment: Anorexia). It argues that the judge in that case made the correct decision in holding that the patient, who suffered from severe anorexia nervosa, lacked capacity to make valid advance directives under the Mental Capacity Act 2005 of the United Kingdom, and that medical procedures that are apparently against (...) her wishes should be carried out for the sake of preserving her life. The law should generally not permit patients with anorexia nervosa to decline nutrition and hydration, precisely because their autonomous ability to make such decisions has been substantially circumscribed by this psychiatric condition. (shrink)

People who suffer from eating disorders often have to be treated against their will, perhaps by being detained, perhaps by being forced to eat. In this paper it is argued that whilst forcing compliance is generally acceptable, there may be circumstances under which a sufferer's refusal of consent to treatment should be respected. This argument will hinge upon whether someone in the grip of an eating disorder can actually make competent decisions about their quality of life. If so, then the (...) decision to refuse therapy may be on a par with other decisions to refuse life‐prolonging therapy made by sufferers of debilitating chronic, or acute onset terminal illness. In such cases, palliation might justifiably replace aggressive therapy. The argument will also draw heavily on the distinction between competent refusal of therapy and passive euthanasia, and the distinction between incompetent and irrational decisions. Both distinctions will then be applied to decisions to refuse food. The extent to which sufferers from anorexia nervosa can be categorised as either incompetent or irrational will be examined. It is against this background that it will be argued that at least some of those who suffer from eating disorders should have their refusals respected, even if they may die as a result. (shrink)

Anorexia nervosa is a psychiatric disorder that seems to be closely related to the identity of the person suffering from it. This is referred to in the vast literature on anorexia nervosa by specifying the quality of symptoms as ‘egosyntonic’ (e.g., Vitousek, Watson, and Wilson 1998). The pursuit of excessive thinness is part of a search for identity in which the control of the body—its size and needs—becomes central (Gillett 2009). This need for control seems to be triggered (...) by a state of bodily alienation in which the body is perceived to be foreign and horrifying to its bearer. However, the relentless dieting and excessive exercise pursued by the anorexic person eventually lead to a state of starvation in which .. (shrink)

The principles that usually direct ethical decision making are not easily or straightforwardly applicable to the care and treatment of anorexia nervosa, particularly the care and treatment of severe and enduring anorexia nervosa, where the sufferer seems to be recalcitrant to treatment and where the condition has become life-threatening.There are exceptional circumstances that characterize this puzzling and still scarcely understood condition; I suggest that these exceptional circumstances provide moral reasons for partial derogation from the usual principles of ethical (...) decision making.In what follows I argue... (shrink)

In this insightful and well-argued article, Osler aims to provide a more fine-grained, phenomenological account of anorectic bodily experience. She notes that although anorexia nervosa often is understood in terms of a distorted body image, this approach does not exhaustively or accurately reflect many subjects' bodily experiences, and also unduly privileges a third-person perspective over first-person accounts. In addition, focusing primarily on body image gives rise to the impression that AN is a form of radical dieting gone wrong as (...) a result of misperceiving or misjudging one's body size or shape. Osler emphasizes that AN is not a static disorder, but rather involves numerous stages. To account for the... (shrink)