Treatment of Eating Disorders

Bridging the Research-practice Gap

Margo Maine, Beth Hartman McGilley, Douglas Bunnell, Margo Maine, Beth Hartman McGilley, Douglas Bunnell

• Publisher: Academic Press
• Year: 2010
• ISBN:
  9780123756695
• Topic: Psychologie
• Subtopic: Klinische Psychologie

Eating disorders (EDs) affect at least 11 million people in the United States each year and spread across age, race, ethnicity and socio-economic class. While professional literature on the subject has grown a great deal in the past 30 years, it tends to be exclusively research-based and lacking expert clinical commentary on treatment. This volume focuses on just such commentary, with chapters authored by both expert clinicians and researchers. Core issues such as assessment and diagnosis, the correlation between EDs and weight and nutrition, and medical/psychiatric management are discussed, as are the underrepresented issues of treatment differences based on gender and culture, the applications of neuroscience, EDNOS, comorbid psychiatric disorders and the impact of psychiatric medications. This volume uniquely bridges the gap between theoretical findings and actual practice, borrowing a bench-to-bedside approach from medical research.

• Includes real-world clinical findings that will improve the level of care readers can provide, consolidated in one place
• Underrepresented issues such as gender, culture, EDNOS and comorbidity are covered in full
• Represents outstanding scholarship, with each chapter written by an expert in the topic area

Chapter 1. A Perfect Biopsychosocial Storm

Gender, Culture, and Eating Disorders

Margo Maine and Douglas W. Bunnell

Although eating disorder(s) (ED) are multidetermined, biopsychosocial disorders, gender alone remains the single-best predictor of their risk (Striegel-Moore & Bulik, 2007). Most research asserts that anorexia nervosa (AN) and bulimia nervosa (BN) are 10 times more common in females than males, and binge-eating disorder (BED) is three times more common (Treasure, 2007). While some have argued that one in six cases occurs in males (Andersen, 2002), the gender disparity is still glaring. Furthermore, while ED is not the only gendered psychiatric condition, the degree of gender disparity is much greater than in most diagnoses (Levine & Smolak, 2006).

Now the third most common illness in adolescent females (Fisher et al., 1995), superseded only by diabetes and asthma, ED have become a major public health issue, affecting more and more women of all ages. Today they appear in every stratum of American culture and, with the impact of globalization, in more than 40 countries worldwide (Gordon, 2001). This exponential increase in a condition disproportionately affecting women must have its roots in the interplay of culture and gender, as a genetic mutation has not swept the globe. But media images of perfectly crafted female bodies and unprecedented role change have, in fact, swept the globe. The increased access to education and involvement in the workplace have transformed women’s social roles dramatically, with rapid technological and market changes introducing a powerful global consumer culture and relentless expectations about appearance and beauty (Gordon, 2001). As the social changes accelerate, many women seek solace and mastery by controlling their bodies (Maine & Kelly, 2005).

Quite simply, gender creates risk. The World Health Organization’s (WHO) evidence-based review of women’s mental health (World Health Organization, 2000) concludes that gender is the strongest determinant of mental health, social position, and status, as well as the strongest determinant of exposure to events and conditions endangering mental health and stability. Furthermore, the WHO notes a positive relationship between the frequency and severity of social stressors and the frequency and severity of mental health problems in women. Despite the importance of gender disparities in mental health and risk for ED, the recent emphasis on biogenetic research risks minimizing the importance of the role of culture and gender in their etiology. As clinicians, we understand that the biopsychosocial whole is greater than the sum of its parts, despite the challenges this presents to the traditional research paradigms. This chapter explores the interplay of biopsychosocial factors contributing to the perfect storm of ED, especially examining culture and gender.

NATURE VERSUS NURTURE: A FALSE DICHOTOMY

Delineations between the biological, psychological, and social forces underlying ED are false distinctions, as nature and nurture always go hand in hand. Genes code RNA and DNA, the building blocks of cells, creating variations associated with risk. While they do not code behavior or disease, genes create vulnerabilities which will be tempered or intensified by other factors (Chavez & Insel, 2007), such as the family, early development, social experiences and expectations, physical conditions, and gender. Increasingly sophisticated research models investigate the complicated interactions in which environmental experience can alter gene expression (Hunter, 2005). Although they are not destiny, genes shape vulnerability and resilience, affecting how we perceive, organize, and respond to experiences, and contributing to the perfect storm of ED.

The rapid decline in the age at which girls enter puberty is an apt example of such a biopsychosocial storm. A century ago, the average age for menarche was 14.2 and now it is 12.3. In the 1970s, the average age of breast development was 11.5, but by 1997, it was less than 10 years old for Caucasian girls and 9 years old for African American girls, with a significant number developing even before age 8 (Steingraber, 2009). Girls who enter puberty earlier than peers have more self-esteem issues, anxiety, depression, adjustment reactions, eating disorders, and suicide attempts (Graber, Seeley, Brooks-Gunn & Lewinsohn, 2004). They are more likely to use drugs, alcohol, and tobacco, have earlier sexual experiences, be at increased risk of physical violence, and, due to prolonged estrogen exposure, have a higher incidence of breast cancer (Steingraber, 2009).

Early puberty may be best understood as an ecological disorder, an interaction of psychosocial, nutritional and environmental triggers, such as pollutants or chemical exposure; while family stress or trauma may also play a part. Aptly describing the false dichotomy between nature and nurture, Steingraber states: “The entire hormonal system has been subtly rewired by modern stimuli…female sexual maturation is not controlled by a ticking clock. It’s more like a musical performance with girls’ bodies as the keyboards and the environment as the pianist’s hands” (2009, p. 52).

Sexual maturation brings increased attention to the body, sexuality, and the developmental pressures of adolescence, enhancing the impact of other ED risk-factors. Nature and nurture interact as girls’ lives unfold.

GENDER: DIFFERENCE OR SIMILARITY?

Culturally constructed sexism has led to intense divisions between men and women, as expressed in common concepts such as “the war of the sexes,” as if gender creates virtually different species with no hope of understanding each other. The media systematically promulgate gender differences, just as they have contributed to the objectification of women and sexism. Despite the popularity of books like Men Are from Mars, Women Are from Venus (Gray, 1995) and You Just Don’t Understand: Men and Women in Conversation (Tannen, 2001), decades of psychological research suggest that men and women and boys and girls are much more alike than different (Hyde, 2005).

In their epic work, The Psychology of Sex Differences, Maccoby and Jacklin (1974) reviewed more than 2000 studies, dismissing many popular beliefs and identifying only four areas of difference: (i) verbal ability; (ii) visual-spatial ability; (iii) mathematical ability; and (iv) aggression. In 2005, Hyde’s meta-analysis of the gender difference literature found that 78% of the differences are very small, actually close to zero, even in areas where gender differences have been consistently considered strong. The greatest gender difference is in motor performance, due to post-puberty differences in muscle mass and bone size. Measures of sexuality, especially the frequency of masturbation and attitudes toward “casual sex,” also reveal significant gender differences, but virtually no difference in reported sexual satisfaction. The meta-analysis of aggression indicates a strong gender difference in physical parameters, but less so with verbal aggression. Despite the suggestion in the popular press and media that girls have a higher level of relational aggression, the evidence is mixed.

As gender differences fluctuate over the course of development, Hyde (2005) suggests that they are not as fixed as many believe. She also notes that the surrounding context, such as the written instructions, interactions between participant and experimenter, or expectations of gender differences, significantly affect results. The fact that both their strength and their direction depends on context challenges the notion of strong, stable gender differences.

NATURE, NURTURE, AND THE BRAIN

Research on the brain indicates important gender differences, despite the behavioral similarities noted above. In a thorough review of gender, Cahill (2006) noted significant gendered patterns in brain structure and neurochemistry associated with a wide range of emotional and cognitive functions including learning, emotional and social processing, memory storage, and decision-making. Male and female brains react differently to stress. Chronic stress is more damaging to the male brain, particularly to the hippocampal area thought to be central to memory and learning, while transitory interpersonal stressors result in a stronger adrenocortical response in women’s brains (Stroud, 1999). At the neurochemical level, gender influences the ways in which our brains synthesize, metabolize, and respond to neurotransmitters such as serotonin, possibly helping to explain differential rates of mood disorders and substance addiction.

Brain differences have been disproportionately attributed to sex hormones, but research has now established that other distinctions exist. For example, the denser corpus callosum (the band of fibers bridging the brain’s hemispheres) in the female brain allows greater connection between the two hemispheres, so women have less lateral specialization, whereas men have more of a division between the brain hemispheres. These neuroanatomical differences may explain women’s superior language skills and men’s superior visual-spatial skills. The neuroanatomy of the hypothalamus, instrumental in hormonal functions and reproduction, is also different, resulting in neurophysiological differences that in turn affect behavior. The anterior cingulate gyrus, more active in women, is linked to nurturant social beh...