Effects of Maladaptive Cognition on the Onset and Development of Anorexia Nervosa
Yeonhee Jenny Kang
Various studies have been conducted on the causative factors for anorexia nervosa (AN) as well as on the factors that influence its development, with many references to terms such as “body image”, “self-schemas”, and “self-concept”; however, these terms are loosely used and rarely clearly defined within the studies. The newly updated Diagnostic and Statistical Manual of Mental Disorders (DSM-5) defines one of the three diagnostic criteria for AN as a ¨disturbance in the way in which one’s body weight or shape is experienced, undue influence of body weight or shape on self-evaluation, or persistent lack of recognition of the seriousness of the current low body weight¨ (American Psychiatric Association, 2013), in which the perception of body weight and shape by the individual are distorted; AN individuals tend to overestimate their own body size in images (Madsen, Bohon & Feusner, 2013). The onset and development of AN is heavily affected by maladaptive self-schemas and body image disturbances. Because this maladaptive cognition is crucially important in the diagnosis of AN as well as the predisposal and risk for AN, it is necessary to place greater emphasis on these factors during research for the potential improvement in treatment and prevention of AN.
Self-schemas as Predictors of Disordered Eating Behaviors
In Stein & Corte’s (2008) Identity Impairment Model research study, an individual’s identity is defined as a compilation of memory structures concerning the self that can alternatively be referred to as the “self-concept”. Similarly, the self-concept is defined as a complex cognitive structure that consists of various self-schemas, which are referred to as “individual organizations of knowledge about the self in specific domains of emotional and behavioral commitment” (Stein & Corte, 2008, p. 182). This longitudinal study aimed to observe the effects of fat body weight self-schemas and other negative weight-related self-schemas as predictors of disordered eating behaviors (DEB) in a group of college women at risk for an eating disorder transitioning from their first to second year of university (Stein & Corte, 2008). Compared to the baseline data measurements of DEB (t=0 months), data collected at the 6 month and 12 month intervals indicated that individuals with negatively valenced self-schemas had increases in their DEB, and the results suggested that these schemas were predictive of increases in DEB (Stein & Corte, 2008); this finding is substantiated by a previous finding that self-schemas motivate and regulate behavior (Stein & Corte, 2003).
This study was conducted over a period of 12 months on a population of 118 college freshman women, with the DEB group consisting of 77 women who had subthreshold levels of DEB and exhibited at least one eating disorder (ED) behavior (restricting, fasting, binging, purging, etc.), and the control group consisting of 41 women with no weight concerns. Both research groups had no history of DEB/ED treatment, and both groups of women were in the normal range for body mass index (Stein & Corte, 2008). Valenced self-schemas were collected through a questionnaire and self-recorded observations of attributes of self on index cards, and body weight self-schemas were recorded through closed-ended self-report measures in which participants had to identify to self-descriptive adjectives by answering “Me/Not me” when exposed to the descriptions (Stein & Corte, 2008).
Results showed that the DEB group reported more negatively valenced self-schemas as well as more “fat words” being attributed as self-descriptive in comparison to the control group (Stein & Corte, 2008). Comparably, the Eating Disorder Inventory (EDI) taken at the end of the 12 month survey indicated that, at the end of the study, all members of the DEB group had EDI-BD (EDI-Body Dissatisfaction) scores and EDI-DFT (EDI-Drive For Thinness) scores in the clinical range for ED (Stein & Corte, 2008). These results suggest the possibility of fat self-schemas and negative attributions to the body as indicators of or direct contributors to the onset and development of DEB. Negatively valenced self-schemas lead to negative affect, inhibition, and behavioral avoidance, and valence and organization of self-schemas influence emotional and behavioral self-regulation; self-concept that is comprised of few positive and many negative self-schemas contributes to the formation of a fat self-schema, which in turn leads to body dissatisfaction and disordered eating (Stein & Corte, 2003). Stein & Corte’s findings support the hypothesis that cognition directly affects and contributes to DEB, with a possibility of being a precursor to the onset of AN; disturbances in self-cognitions appear to contribute to the development of DEBs as well as to the onset of diagnosable levels of ED (Stein & Corte, 2008).
One of the limitations of this study was that the population surveyed was solely from one single age group, college freshmen, and this age group is known to be in the peak period of the onset of ED symptoms as well as the period when these symptoms begin to consolidate into a diagnosable, stable disorder (Stein & Corte, 2008). This brings up the question of external confounding factors that may influence results or trigger diathesis in that time specific frame. In addition, only 19.5% of the surveyed population was non-White, which might have accounted for an inaccurate population sample due to the small number of participants selected to survey from one single background (the same university). Finally, only 73% (56) and 72% (55) of the initial 77 women in the DEB group completed data for the 6 and 12 month follow up data collections, respectively, which indicates a possibility for skewed and inflated percentages in the concluding data in relation to the initial data collected and calculated (Stein & Corte, 2008). For possible future research methods, a longer longitudinal study that extended the time period studied could be helpful in determining the effect on maladaptive self-schemas with respect to the prediction of a diagnosis of AN as well as the escalation of DEB over time.
Cultural Body Shape Ideals and Eating Disorder Symptoms
Gordon, Sitnikov, Castro and Holm-Denoma (2010) conducted a study that added another variable that may influence the effects of body ideals and self-images on ED: culture. By introducing this new variable, researchers strengthened support that maladaptive cognition does have a significant effect on AN, even across multicultural backgrounds in populations. In order to measure the differences of body image ideals and its effects on ED symptoms, acculturation was also taken into consideration; the researchers hypothesized that if levels of acculturation, defined as the extent to which an individual embraces mainstream society values, were higher, the effects of mainstream U.S. body ideals on ED symptoms would be the same cross-culturally (Gordon et al., 2010).
This study was conducted at a university, drawing a sample population of 276 women from an introductory psychology class; 29% (n=79) of the surveyed population were White, 44% (n=122) were Black, and 27% (n=75) were Latina (Gordon et al., 2010). This imbalance in ethnic group samples was purposefully done to oversample women of minority groups in order to maintain the focus on this variable (Gordon et al., 2010). The measures used to collect data over the course of three semesters were: the Eating Disorder Inventory (EDI), to test for Drive for Thinness (EDI-DFT) and Body Dissatisfaction (EDI-BD), the Stunkard Body Figure Scale (BFS), to test for: 1) the individual’s ethnic group’s ideal body shape, 2) the perceived U.S. mainstream cultural ideal body shape, 3) personal ideal body shape, and 4) perceived body shape, the Stephenson Multigroup Acculturation Scale (SMAS), to determine levels of acculturation, the Societal, Attitudinal, Familial, and Environmental Acculturative Stress Scale (SAFE), and the Rosenberg Self-Esteem Scale (RSE), to measure and assess self-reported levels of self-esteem because “[self-esteem] is a well-established correlate of ED symptoms” (Gordon et al., 2010, p. 138).
Results of this study showed that for the EDI-DFT and EDI-BD scores, no significant difference was found between White, Black, and Latino group scores; similarly, reported personal ideal body shape, mainstream body ideals, and perceived current body shape for all ethnic groups showed no group differences, but all self-reported groups displayed high BD and DFT scores, as well as a overestimation of perceived current body shape (Gordon et al., 2010). Perceived ideal body sizes for one’s ethnic group showed minute differences throughout the ethnic groups, and “self-esteem scores were predictive of all [two] EDI subscales for both the Latino and Black participant groups” (Gordon et al., 2010, p. 139), Body size estimation requires a construction or activation of a memory of the physical self, and this inability to estimate size accurately may be an indicator that, rather than a perceptual deficit or issue, “cognitive representations of the physical self are inaccurate or are cognitive products based on comparison to unrealistic standards” (Stein & Corte, 2003, p. 59).
The findings of this study show that all ethnic backgrounds are vulnerable to the onset of AN when exposed to U.S. thin ideals and experience dissatisfaction as well as an overestimation of one’s body type in conjunction with slimmer perceived mainstream ideal body shape and personal ideal body shape (Gordon et al., 2010); this did not support the stereotype that “only white American women develop [ED] and… ethnic minority groups report lower rates of body dissatisfaction” (Gordon et al., 2010, p. 135). These discrepancies between perceived body shape and perceived mainstream ideal body shape, along with the correlation of low self-esteem and high body dissatisfaction, seem to suggest a predictive indicator of AN symptoms. High levels of acculturation and acculturative stress were also correlated with higher levels of DFT among the women surveyed and maladaptive coping strategies were used in an attempt to “fit into the mainstream through attainment of the thin ideal” (Gordon et al., 2010, p. 141), suggesting a causative relationship.
Limitations of this study were that the sample population was drawn from a single socioeconomic class in a predominately White, American university, where acculturation scores were all high and there were no members of the mentioned ethnic groups to serve as a less accultured example to serve for comparison. Similarly, a control group was not utilized at all in this study, which causes difficulty in comparison of results. In addition, three semesters of data were collected with collection at the end of each semester; however, the White ethnic group’s data was solely collected in the first semester, leaving the data sheets empty for the second and third semesters.
This deliberate exclusion of data collection in the second and third semesters for the predominately White group, in addition to the population oversampling of the other two minority ethnic groups, causes more difficulty in comparison of data, as well as potential inaccuracy when comparing final data from the two minority ethnic groups to the first semester data collected from the White ethnic group. Future research could explore the effects of body shape ideals and dissatisfactions on a longitudinal base with a complete set of data collected from all ethnic groups, to accurately compare the predictors of ED symptoms observed in this study to DEB and/or ED symptoms that develop to a clinical level of severity.
Relationships between Body Esteem and Risk for Anorexia Nervosa
“Research suggests that impulsivity… and [b]ody dissatisfaction [are] consistently linked to heightened risk for disordered eating patterns and [are] considered a robust and consistent predictor of eating disorder pathology” (Lilienthal & Weatherly, 2013, p. 558); however, an important distinction from the formerly prevalent views should be made, because “[c]ontrary to the popular view that conceptions of the self as fat are normative, results… suggest that only a subset of young adult women have an elaborated and stable cognitive structure of the self as fat, and those who do demonstrate patterns of DEB behavior” (Stein & Corte, 2008, p. 189). In this study on cognition and AN, Lilienthal and Weatherly (2013) explore the relationship between the risk for AN and low body esteem, while incorporating a different type of maladaptive cognition: impulsivity.
Methods for this survey included a population sample of 139 female students from a single university, many of whom (94.2%, n=131) were Caucasian, with 60% (n=84) of the participants attempting to lose weight at the time of the study (Lilienthal & Weatherly, 2013). Data measures were recorded using: the Body-Esteem Scale for Adolescents and Adults (BESAA), to record body image and esteem, the EAT-16 scale, to measure risk for AN, and a multiple-choice questionnaire, to measure discounting behavior in gaining/losing weight and improving/worsening complexion in order to determine levels of impulsivity in different situations.
Results of this study showed that a sign effect occurred within the tested population, showing differences in discounting behaviors depending on whether theoretical outcomes were presented as gains or losses. The majority of students showed reduced discounting for a hypothetical delayed monetary loss; this implies that their behaviors could be predictive for ED behaviors because AN patients’ behaviors are “strongly controlled by avoiding negative outcomes… individuals with [AN]... cope with stress using primarily avoidance-based strategies” (Lilienthal & Weatherly, 2013, p. 559). This result is significant because the discounting tasks were primarily focused on body weight and appearance, two crucial aspects of AN, and yielded important information on possible traits, specifically to do with cognition, that could be likely to “trigger problematic… disrupted eating/weight-control problems” (Lilienthal & Weatherly, 2013, p. 560).
Another finding of the study was the suggestion that higher body esteem is directly related to a lower risk for developing AN, due to higher levels of reduced impulsive avoidant behavior in the discounting task data collections. Conversely, those who reported lower levels of body esteem showed “lower impulsive responding regarding opportunities to lose weight” and demonstrated a greater risk for AN (Lilienthal & Weatherly, 2013, p. 562).
The limitations for this study were that, out of the 139 participants, 131 were Caucasian and not many other ethnic groups were represented equally; this predominately yields results applicable solely to Caucasians, and cannot accurately be applied to other ethnic groups. Additionally, risk for AN was solely determined by a single factor, the EAT-16 self-reporting scale meant to detect likelihood for developing AN; however, unlike Bulimia nervosa, because of the characteristics of AN patients and those at risk for AN often being in denial and refusing to admit habits and symptoms honestly, a single 16 item questionnaire might not be enough to solely determine the risk factors for AN on an individual. If more methods such as the Eating Disorder Inventory were to be implemented in addition to these tests, the results determining risk for AN would be more accurate and less prone to miscalculation with more data available.
Conclusion and Potential Future Direction
Although negative cognition and terms such as “thin ideal”, “body image”, and “self-schemas” have often been used in conjunction with the topic of AN, not much research exists on the direct effects that these factors can have on the onset as well as the development of AN. In the Lilitenthal & Weatherly study, the usage of avoidance-based strategies to cope with stress as well as the suggestion that higher body esteem is directly related to a lower risk for developing AN was seen as variables strongly correlated with AN. Gordon et al. found that dissatisfaction and overestimation of body shape were risk factors for developing AN, and Stein & Corte found that negatively valenced self-schemas and negative attributions to the body were predictors for disordered eating behaviors. All of these findings have one thing in common: cognition. These associations have been clearly established, but the direct effects of these variables have not been studied in detail.
If research implementing cognitive-behavioral therapy to adjust coping strategies, body esteem, dissatisfaction and overestimation of body shape, and negative self-schemas in individuals diagnosed with AN or at risk for AN is conducted, prevention and treatment for AN could make great headway. Because maladaptive cognition can affect and exacerbate the restricting and obsessive behaviors that characterize AN, findings from the aforementioned studies should be utilized to conduct more longitudinal research, in order to understand what types of cognition affect a diathesis or predisposition for developing AN. Additionally, treatment time should more specifically be devoted to cognition, because this information could also be used to enhance preventative therapy for at-risk patients, as well as to enhance current treatment methods following diagnosis of AN. In the future, the prevention and treatment of AN should have a stronger focus on cognitive therapy with respect to altering schemas and body image disturbances to represent a more accurate image of the patients’ selves and to advance existing literature and knowledge on the subject.
References
American Psychiatric Association. (2013). Feeding and eating disorders. In Diagnostic and statistical manual of mental disorders (5th ed.). doi:10.1176/appi.books.9780890425596.323864
Gordon, K. H., Sitnikov, L., Castro, Y., & Holm-Denoma, J. M. (2010). Cultural body shape ideals and eating disorder symptoms among white, latina, and black college women. Cultural Diversity and Ethnic Minority Psychology, 16(2), 135-143.
Lilienthal, K. R., & Weatherly, J. N. (2013). Understanding the relationships between body esteem, risk for anorexia nervosa, and domain-dependent decision-making impulsivity in a college sample. Body Image, 10, 558-565.
Madsen, S. K., Bohon, C., & Feusner, J. D. (2013). Visual processing in anorexia nervosa and body dysmorphic disorder: Similarities, differences, and future research directions. Journal of Psychiatric Research, 47, 1483-1491.
Stein, K. F., & Corte, C. (2008). The identity impairment model: A longitudinal study of self-schemas as predictors of disordered eating behaviors. Nursing Research, 57(3), 182-190.
Stein, K. F., & Corte, C. (2003). Reconceptualizing causative factors and intervention strategies in the eating disorders: A shift from body image to self-concept impairments. Archives of Psychiatric Nursing, 17(2), 57-66.
Self-schemas as Predictors of Disordered Eating Behaviors
In Stein & Corte’s (2008) Identity Impairment Model research study, an individual’s identity is defined as a compilation of memory structures concerning the self that can alternatively be referred to as the “self-concept”. Similarly, the self-concept is defined as a complex cognitive structure that consists of various self-schemas, which are referred to as “individual organizations of knowledge about the self in specific domains of emotional and behavioral commitment” (Stein & Corte, 2008, p. 182). This longitudinal study aimed to observe the effects of fat body weight self-schemas and other negative weight-related self-schemas as predictors of disordered eating behaviors (DEB) in a group of college women at risk for an eating disorder transitioning from their first to second year of university (Stein & Corte, 2008). Compared to the baseline data measurements of DEB (t=0 months), data collected at the 6 month and 12 month intervals indicated that individuals with negatively valenced self-schemas had increases in their DEB, and the results suggested that these schemas were predictive of increases in DEB (Stein & Corte, 2008); this finding is substantiated by a previous finding that self-schemas motivate and regulate behavior (Stein & Corte, 2003).
This study was conducted over a period of 12 months on a population of 118 college freshman women, with the DEB group consisting of 77 women who had subthreshold levels of DEB and exhibited at least one eating disorder (ED) behavior (restricting, fasting, binging, purging, etc.), and the control group consisting of 41 women with no weight concerns. Both research groups had no history of DEB/ED treatment, and both groups of women were in the normal range for body mass index (Stein & Corte, 2008). Valenced self-schemas were collected through a questionnaire and self-recorded observations of attributes of self on index cards, and body weight self-schemas were recorded through closed-ended self-report measures in which participants had to identify to self-descriptive adjectives by answering “Me/Not me” when exposed to the descriptions (Stein & Corte, 2008).
Results showed that the DEB group reported more negatively valenced self-schemas as well as more “fat words” being attributed as self-descriptive in comparison to the control group (Stein & Corte, 2008). Comparably, the Eating Disorder Inventory (EDI) taken at the end of the 12 month survey indicated that, at the end of the study, all members of the DEB group had EDI-BD (EDI-Body Dissatisfaction) scores and EDI-DFT (EDI-Drive For Thinness) scores in the clinical range for ED (Stein & Corte, 2008). These results suggest the possibility of fat self-schemas and negative attributions to the body as indicators of or direct contributors to the onset and development of DEB. Negatively valenced self-schemas lead to negative affect, inhibition, and behavioral avoidance, and valence and organization of self-schemas influence emotional and behavioral self-regulation; self-concept that is comprised of few positive and many negative self-schemas contributes to the formation of a fat self-schema, which in turn leads to body dissatisfaction and disordered eating (Stein & Corte, 2003). Stein & Corte’s findings support the hypothesis that cognition directly affects and contributes to DEB, with a possibility of being a precursor to the onset of AN; disturbances in self-cognitions appear to contribute to the development of DEBs as well as to the onset of diagnosable levels of ED (Stein & Corte, 2008).
One of the limitations of this study was that the population surveyed was solely from one single age group, college freshmen, and this age group is known to be in the peak period of the onset of ED symptoms as well as the period when these symptoms begin to consolidate into a diagnosable, stable disorder (Stein & Corte, 2008). This brings up the question of external confounding factors that may influence results or trigger diathesis in that time specific frame. In addition, only 19.5% of the surveyed population was non-White, which might have accounted for an inaccurate population sample due to the small number of participants selected to survey from one single background (the same university). Finally, only 73% (56) and 72% (55) of the initial 77 women in the DEB group completed data for the 6 and 12 month follow up data collections, respectively, which indicates a possibility for skewed and inflated percentages in the concluding data in relation to the initial data collected and calculated (Stein & Corte, 2008). For possible future research methods, a longer longitudinal study that extended the time period studied could be helpful in determining the effect on maladaptive self-schemas with respect to the prediction of a diagnosis of AN as well as the escalation of DEB over time.
Cultural Body Shape Ideals and Eating Disorder Symptoms
Gordon, Sitnikov, Castro and Holm-Denoma (2010) conducted a study that added another variable that may influence the effects of body ideals and self-images on ED: culture. By introducing this new variable, researchers strengthened support that maladaptive cognition does have a significant effect on AN, even across multicultural backgrounds in populations. In order to measure the differences of body image ideals and its effects on ED symptoms, acculturation was also taken into consideration; the researchers hypothesized that if levels of acculturation, defined as the extent to which an individual embraces mainstream society values, were higher, the effects of mainstream U.S. body ideals on ED symptoms would be the same cross-culturally (Gordon et al., 2010).
This study was conducted at a university, drawing a sample population of 276 women from an introductory psychology class; 29% (n=79) of the surveyed population were White, 44% (n=122) were Black, and 27% (n=75) were Latina (Gordon et al., 2010). This imbalance in ethnic group samples was purposefully done to oversample women of minority groups in order to maintain the focus on this variable (Gordon et al., 2010). The measures used to collect data over the course of three semesters were: the Eating Disorder Inventory (EDI), to test for Drive for Thinness (EDI-DFT) and Body Dissatisfaction (EDI-BD), the Stunkard Body Figure Scale (BFS), to test for: 1) the individual’s ethnic group’s ideal body shape, 2) the perceived U.S. mainstream cultural ideal body shape, 3) personal ideal body shape, and 4) perceived body shape, the Stephenson Multigroup Acculturation Scale (SMAS), to determine levels of acculturation, the Societal, Attitudinal, Familial, and Environmental Acculturative Stress Scale (SAFE), and the Rosenberg Self-Esteem Scale (RSE), to measure and assess self-reported levels of self-esteem because “[self-esteem] is a well-established correlate of ED symptoms” (Gordon et al., 2010, p. 138).
Results of this study showed that for the EDI-DFT and EDI-BD scores, no significant difference was found between White, Black, and Latino group scores; similarly, reported personal ideal body shape, mainstream body ideals, and perceived current body shape for all ethnic groups showed no group differences, but all self-reported groups displayed high BD and DFT scores, as well as a overestimation of perceived current body shape (Gordon et al., 2010). Perceived ideal body sizes for one’s ethnic group showed minute differences throughout the ethnic groups, and “self-esteem scores were predictive of all [two] EDI subscales for both the Latino and Black participant groups” (Gordon et al., 2010, p. 139), Body size estimation requires a construction or activation of a memory of the physical self, and this inability to estimate size accurately may be an indicator that, rather than a perceptual deficit or issue, “cognitive representations of the physical self are inaccurate or are cognitive products based on comparison to unrealistic standards” (Stein & Corte, 2003, p. 59).
The findings of this study show that all ethnic backgrounds are vulnerable to the onset of AN when exposed to U.S. thin ideals and experience dissatisfaction as well as an overestimation of one’s body type in conjunction with slimmer perceived mainstream ideal body shape and personal ideal body shape (Gordon et al., 2010); this did not support the stereotype that “only white American women develop [ED] and… ethnic minority groups report lower rates of body dissatisfaction” (Gordon et al., 2010, p. 135). These discrepancies between perceived body shape and perceived mainstream ideal body shape, along with the correlation of low self-esteem and high body dissatisfaction, seem to suggest a predictive indicator of AN symptoms. High levels of acculturation and acculturative stress were also correlated with higher levels of DFT among the women surveyed and maladaptive coping strategies were used in an attempt to “fit into the mainstream through attainment of the thin ideal” (Gordon et al., 2010, p. 141), suggesting a causative relationship.
Limitations of this study were that the sample population was drawn from a single socioeconomic class in a predominately White, American university, where acculturation scores were all high and there were no members of the mentioned ethnic groups to serve as a less accultured example to serve for comparison. Similarly, a control group was not utilized at all in this study, which causes difficulty in comparison of results. In addition, three semesters of data were collected with collection at the end of each semester; however, the White ethnic group’s data was solely collected in the first semester, leaving the data sheets empty for the second and third semesters.
This deliberate exclusion of data collection in the second and third semesters for the predominately White group, in addition to the population oversampling of the other two minority ethnic groups, causes more difficulty in comparison of data, as well as potential inaccuracy when comparing final data from the two minority ethnic groups to the first semester data collected from the White ethnic group. Future research could explore the effects of body shape ideals and dissatisfactions on a longitudinal base with a complete set of data collected from all ethnic groups, to accurately compare the predictors of ED symptoms observed in this study to DEB and/or ED symptoms that develop to a clinical level of severity.
Relationships between Body Esteem and Risk for Anorexia Nervosa
“Research suggests that impulsivity… and [b]ody dissatisfaction [are] consistently linked to heightened risk for disordered eating patterns and [are] considered a robust and consistent predictor of eating disorder pathology” (Lilienthal & Weatherly, 2013, p. 558); however, an important distinction from the formerly prevalent views should be made, because “[c]ontrary to the popular view that conceptions of the self as fat are normative, results… suggest that only a subset of young adult women have an elaborated and stable cognitive structure of the self as fat, and those who do demonstrate patterns of DEB behavior” (Stein & Corte, 2008, p. 189). In this study on cognition and AN, Lilienthal and Weatherly (2013) explore the relationship between the risk for AN and low body esteem, while incorporating a different type of maladaptive cognition: impulsivity.
Methods for this survey included a population sample of 139 female students from a single university, many of whom (94.2%, n=131) were Caucasian, with 60% (n=84) of the participants attempting to lose weight at the time of the study (Lilienthal & Weatherly, 2013). Data measures were recorded using: the Body-Esteem Scale for Adolescents and Adults (BESAA), to record body image and esteem, the EAT-16 scale, to measure risk for AN, and a multiple-choice questionnaire, to measure discounting behavior in gaining/losing weight and improving/worsening complexion in order to determine levels of impulsivity in different situations.
Results of this study showed that a sign effect occurred within the tested population, showing differences in discounting behaviors depending on whether theoretical outcomes were presented as gains or losses. The majority of students showed reduced discounting for a hypothetical delayed monetary loss; this implies that their behaviors could be predictive for ED behaviors because AN patients’ behaviors are “strongly controlled by avoiding negative outcomes… individuals with [AN]... cope with stress using primarily avoidance-based strategies” (Lilienthal & Weatherly, 2013, p. 559). This result is significant because the discounting tasks were primarily focused on body weight and appearance, two crucial aspects of AN, and yielded important information on possible traits, specifically to do with cognition, that could be likely to “trigger problematic… disrupted eating/weight-control problems” (Lilienthal & Weatherly, 2013, p. 560).
Another finding of the study was the suggestion that higher body esteem is directly related to a lower risk for developing AN, due to higher levels of reduced impulsive avoidant behavior in the discounting task data collections. Conversely, those who reported lower levels of body esteem showed “lower impulsive responding regarding opportunities to lose weight” and demonstrated a greater risk for AN (Lilienthal & Weatherly, 2013, p. 562).
The limitations for this study were that, out of the 139 participants, 131 were Caucasian and not many other ethnic groups were represented equally; this predominately yields results applicable solely to Caucasians, and cannot accurately be applied to other ethnic groups. Additionally, risk for AN was solely determined by a single factor, the EAT-16 self-reporting scale meant to detect likelihood for developing AN; however, unlike Bulimia nervosa, because of the characteristics of AN patients and those at risk for AN often being in denial and refusing to admit habits and symptoms honestly, a single 16 item questionnaire might not be enough to solely determine the risk factors for AN on an individual. If more methods such as the Eating Disorder Inventory were to be implemented in addition to these tests, the results determining risk for AN would be more accurate and less prone to miscalculation with more data available.
Conclusion and Potential Future Direction
Although negative cognition and terms such as “thin ideal”, “body image”, and “self-schemas” have often been used in conjunction with the topic of AN, not much research exists on the direct effects that these factors can have on the onset as well as the development of AN. In the Lilitenthal & Weatherly study, the usage of avoidance-based strategies to cope with stress as well as the suggestion that higher body esteem is directly related to a lower risk for developing AN was seen as variables strongly correlated with AN. Gordon et al. found that dissatisfaction and overestimation of body shape were risk factors for developing AN, and Stein & Corte found that negatively valenced self-schemas and negative attributions to the body were predictors for disordered eating behaviors. All of these findings have one thing in common: cognition. These associations have been clearly established, but the direct effects of these variables have not been studied in detail.
If research implementing cognitive-behavioral therapy to adjust coping strategies, body esteem, dissatisfaction and overestimation of body shape, and negative self-schemas in individuals diagnosed with AN or at risk for AN is conducted, prevention and treatment for AN could make great headway. Because maladaptive cognition can affect and exacerbate the restricting and obsessive behaviors that characterize AN, findings from the aforementioned studies should be utilized to conduct more longitudinal research, in order to understand what types of cognition affect a diathesis or predisposition for developing AN. Additionally, treatment time should more specifically be devoted to cognition, because this information could also be used to enhance preventative therapy for at-risk patients, as well as to enhance current treatment methods following diagnosis of AN. In the future, the prevention and treatment of AN should have a stronger focus on cognitive therapy with respect to altering schemas and body image disturbances to represent a more accurate image of the patients’ selves and to advance existing literature and knowledge on the subject.
References
American Psychiatric Association. (2013). Feeding and eating disorders. In Diagnostic and statistical manual of mental disorders (5th ed.). doi:10.1176/appi.books.9780890425596.323864
Gordon, K. H., Sitnikov, L., Castro, Y., & Holm-Denoma, J. M. (2010). Cultural body shape ideals and eating disorder symptoms among white, latina, and black college women. Cultural Diversity and Ethnic Minority Psychology, 16(2), 135-143.
Lilienthal, K. R., & Weatherly, J. N. (2013). Understanding the relationships between body esteem, risk for anorexia nervosa, and domain-dependent decision-making impulsivity in a college sample. Body Image, 10, 558-565.
Madsen, S. K., Bohon, C., & Feusner, J. D. (2013). Visual processing in anorexia nervosa and body dysmorphic disorder: Similarities, differences, and future research directions. Journal of Psychiatric Research, 47, 1483-1491.
Stein, K. F., & Corte, C. (2008). The identity impairment model: A longitudinal study of self-schemas as predictors of disordered eating behaviors. Nursing Research, 57(3), 182-190.
Stein, K. F., & Corte, C. (2003). Reconceptualizing causative factors and intervention strategies in the eating disorders: A shift from body image to self-concept impairments. Archives of Psychiatric Nursing, 17(2), 57-66.