FROM ACROSS THE DESK: Body Image Under Attack

Dr. Sandra Wartski’s thoughtful essay in this issue spotlights one of the compelling hazards women and men of all ages face in the fast lane of the Internet and electronic and print media—seeing unrealistic images that project a false impression of “perfection.”

The author writes, “These socially constructed ideas of beauty are negatively impacting body image, eating, and a myriad of other areas in people already vulnerable to or struggling to recover from an ED.” One solution, she notes, would be to add warning messages on such ads and promotions, pointing out that these images have been distorted. Just as we warn consumers about harmful products, we need to think about how to warn about the dangers of accepting false images as goals.

Each day through our email, newspapers, magazines, and television, we are bombarded with ads promoting miracle products for dieting and body sculpting, along with articles reminding us, with unrealistic images, that we aren’t perfect–but that we can quickly cure this with a miraculous product or new diet formulation. By the time the consumer reads these ads online or on other media, he or she has already compiled a lifetime of experiences with weight phobia.

As Dr. Wartski notes, an important step in the right direction came with passage of the Anna Westin Act of 2015. On December 13, 2016, in one of his last official acts, then-President Barack Obama signed the Anna Westin Act into law as part of the 21st Century CURES Act. This legislation mandates insurance coverage for advanced eating disorders treatment and eating disorder education for healthcare professionals. The act is named for named for Anna Westin, an anorexia nervosa patient who struggled with body image and AN, and ultimately took her life at age 21 years. Her family, and particularly her mother, psychologist Kitty Westin, determined to be open and honest about Anna’s life and death in a time when it was far more common to remain silent about the ramifications of AN, particularly when it involved suicide of a family member. Westin later co-founded the Eating Disorders Coalition.

The Anna Westin Act clarifies existing mental health parity law to improve health insurance coverage for eating disorders and residential treatment, early identification of eating disorders training for health professionals such as primary care physicians, and enhanced information and resources to help early identification of eating disorders by the public.

Importantly, the Anna Westin Act also provides training and research into common advertising practices like altering images through Photoshop .In coming months, the Federal Trade Commission must submit to Congress a report offering a strategy and recommendations to reduce the use in advertising of images that have been altered to change the physical characteristics of the individuals depicted. In addition, singers Lady GAGA, Sam Smith, and Kelly Clarkson, model Tyra Banks, and actress Alyssa Milano are among a growing number of celebrities who have stepped forward to fight back against negative comments about bodies or appearance.

Warning: Looking and Lamenting May be Lethal

By Sandra Wartski, PsyD, CEDS

Eating disorders are biopsychosocial disorders with multifactorial causes. While science continues to unveil insights into the genetic predisposition and biological influences related to EDs, any clinician working in this field knows that the social influences cannot be ignored. We regularly experience socially constructed ideas of beauty that are negatively impacting body image, eating, and a myriad of other areas in people already vulnerable to or struggling to recover from an ED.

We know it’s harmful. Numerous studies have connected the unrealistic thin ideal so widely portrayed in social media to body dissatisfaction, internalization of an unrealistic body image, and disordered eating. Even the American Medical Association condemned the practice of retouching ad images at their annual meeting in 2011, citing the literature linking “exposure to media-propagated images of unrealistic body image to eating disorders and other child and adolescent health problems.” And now, with technological advances allowing 24/7 contact with powerful visual messages, it is even more difficult for our clients to turn away. Despite the fact that clients know that some of the messages are mythical or only flashy marketing mishmash, the commanding impact of such external stimuli is formidable.

Why Warnings Are Warranted

Educational campaigns have advanced our society in various ways. The slogan “Smoking Kills” is now widely known, and as a result fewer teens are smoking and pregnant women don’t smoke as routinely as they had only a few decades ago. “Don’t drink and drive” messages don’t prevent all of the deaths associated with driving under the influence (DUIs) each year, but DUI numbers – especially for youth – have dropped. A change in mindset can and does happen.

We see warnings on almost everything in our daily life–from antennae to zippers –but such disclaimers are missing from some of the most lethal influences in our current culture. Americans today are much more often engaged in continual comparisons of their bodies, size, attractiveness, and even good fortune by the continual click and scroll on their computers and other devices. We don’t yet have any far-reaching warnings about the fact that constantly looking at certain ads, compulsive body competitiveness, and self-degrading lamenting can damage emotional well-being and psychological stability. But, as President Franklin D. Roosevelt wisely proclaimed, “Comparison is the thief of joy.” ED clinicians often include some therapeutic focus for helping clients approach media influences with a more critical eye. However, without more formalized parameters, we often are a small minority prospectively pushing against a powerful cultural current.

We need more warnings about the toxic social factors that negatively impact social-emotional health. Such warnings can be informative. Warnings currently available with everyday products can be categorized into three primary types: (1) warnings that point out the obvious, (2) warnings that inform, and (3) warnings that provide assistance. ED prevention education could be incorporated effectively in any of those arenas.

Warnings That Point out the Obvious

Warnings we see on everyday objects that point out the obvious include messages such as: “Do not eat the antennae” and “This zipper may harm your penis. Zip with caution.” Although these notifications may seem a bit obvious, or may reflect the individual company’s sense of humor, or may be related to our litigious society, they do catch one’s attention and present the notion of proceeding carefully.

If we were to apply a similar approach for toxic images, there would be some straightforward ways to proceed. With some of the images and advertisements that abound, perhaps warnings that point out the obvious might read, “This model is not real. She has been Photoshopped in 368 ways prior to printing,” or “This claim, ‘lose 20 pounds in 5 days,’ has not been proven, researched or substantiated but is intended only as marketing enticement.” It is not clear that the reader would heed this warning or even consider it, but it might lead to a pause. Individuals might even be helped to create their own periodic reminder alerts when frequenting social media sites, such as, “Remember: people tend to post only the best photo” or “I promise to exit if I start to feel bad.”

Warnings That Inform

When consumers read warnings such as “Made in a factory that processes peanuts,” or “This product contains wheat,” they can proceed with a full awareness of what they are ingesting. Reading “Do not operate machinery while taking this medication” allows the consumer to have informed consent. Seeing “This product contains saccharin, which has been determined to cause cancer in laboratory animals,” is sobering. Knowledge is power.

Similarly, it might be helpful for individuals to know facts such as how engaging in continual social comparisons increases negative thinking and decreases self-confidence. Viewers of a pop-up ad might appreciate knowing that study results have shown that only a few moments of looking at airbrushed fashion models lowers feelings of self-worth and self-respect. Instead of body parts being objectified and criticized, perhaps we could create more visuals of body parts being celebrated and imperfections being exonerated. We might, for instance, post photos showing real bodies with arrows pointing to the fleshy abdominal area, reminding the viewer that this is the powerful area where food is magically transformed into energy, or we might post videos about the strength involved when someone is learning to walk again after an amputation (perhaps with accompanying text about how achieving a thigh gap is no longer a priority).

Warnings That Provide Assistance 

Lottery commercials now routinely give the site for the “Gambling Helpline” at the end of the ad, acknowledging that a percentage of consumers struggle with compulsive gambling. Cleaning products prominently point out the command to call Poison Control if the product has been ingested. There is even growing movement of guidance for those self-identifying as addicted to smoking with the “1-800-QUIT-NOW” campaign.

With EDs, we could focus on the message of helping consumers to “seek out professional help if negative body dissatisfaction is affecting your mood, relationships, and daily living,” supporting the mission of destigmatizing mental health services. Instead of the consumer being left to wonder whether the answer to a depressing image or negative comparisons is to diet, give up, or pile on more self-hatred, perhaps instead there might be a list of helpful hotlines or websites. Catching individuals prior to them spiraling into ED thinking and behaviors is invaluable. We have lived through the decades of public health education geared towards the prevention of various physical diseases, such as how safe sex practices can prevent the spread of HIV; perhaps we now can also support the infusion of more attention to prevention of psychological illnesses.

Initial Research Highlights Complexity 

Research is being conducted on the impact of warning labels and disclaimers, and psychologists Marika Tiggemann and Belinda Bury are among the leaders in the field. 1-3 Initial findings are somewhat contrary to what might be expected, with subjects showing an increase rather than a decrease in body dissatisfaction after viewing ads with warning labels. The researchers conjectured that the subjects may have believed that if these seemingly perfect models needed digital alterations, then any normal human would need even more alterations. It was also hypothesized that the labels may have drawn more, rather than less, attention to the models’ bodies, thus increasing the comparative process. More research in this realm is naturally needed, but these initial findings highlight the complexity of the problem and the ingenuity that will be required for solutions.

Good News: Things Are Changing

Some celebrities are bravely stepping up to oppose digital alterations, and some companies are making a commitment to stop the excessive Photoshopping trend. Documentaries and blogs of people speaking out against this unhealthy social media comparative craze are emerging. For example, last year, the US Senate passed key provisions from the Anna Westin Act, referencing the need for improved information and public service announcements on eating disorders, including the aim of promoting truth in advertising and educating the public on the harmful effects of altered body images in ads. The bipartisan cooperation in passing this bill was a historic event for the eating disorders community (and was among President Obama’s final tasks before leaving office as he signed this bill into law in December 2016). And, this spring, France passed a new law requiring clear indications with any images of models that have been digitally altered. This will not be a panacea, especially given the conflicting research results, but the country is taking a bold stand on this lethal influence.

The Future

Warning labels of the obvious, informational, and assistance types might be only one small step toward interrupting the compulsion to compare. Unlike the straightforward labeling of other products, developing effective social media disclaimers will be much more complex. However, EDs are a serious health hazard that deserves as much consumer awareness as all the other serious and sometimes ridiculous warnings currently out there.

ED clinicians are in ideal positions to lead the way. We see the impact of some of the toxic cultural influences each day and are well suited to assist in this preventative action. As cultural anthropologist Margaret Mead said, “Never doubt that a small group of thoughtful, committed citizens can change the world; indeed, it’s the only thing that ever has.”

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Unraveling Resistance to Change after Weight Is Restored

courtesy of eating disorders review

Clues emerged in a feedback experiment among AN patients and controls.

It is a challenging question: Why do many patients with anorexia nervosa (AN) continue to restrict their calories after their weight is restored and many of their psychiatric symptoms have improved? One possible reason, according to Karin Foerde, PhD and Joanna E. Steinglass, MD of Columbia University, is that AN patients may experience reduced learning from feedback or reinforcement. In their recent study, the same pattern was not seen among healthy controls (Int J Eat Disord. 2017; 50:415).

The researchers wanted to explore why reward processing among AN patients differs from that of normal control patients, and why learning from feedback is not effective. To do so, Drs. Foerde and Steinglass studied patients between 16 and 45 years of age who had DSM-5 diagnoses of AN-restrictive or binge-purge subtype AN (36 patients; 35 females and 1 male). All the subjects were inpatients at the New York State Psychiatric Institute, and were compared with 26 healthy controls (24 females, 2 males). The two groups did not differ in age, educational level, gender, ethnicity, or general cognitive functioning.

After 2 sessions of an association task, individuals with AN showed poorer learning from feedback in comparison with the healthy controls; this pattern was reported both before and after weight was restored. The reduction in feedback learning was associated with eating disorder psychopathology and suggested by the association with some eating disorder symptom severity scales and illness duration—but not with body mass index, or BMI. However, AN patients could generalize from what they had learned, just as the healthy controls did. Their psychological symptoms did get better with weight restoration treatment, but feedback learning did not. Both groups were well matched on global cognition, including IQ, working memory, and attention.

Although the authors’ study involved a behavioral task and no direct studies of the brain, their results were consistent with those of studies that have evaluated various forms of striatal-based learning among AN patients. (J Cognitive Neuroscience (2003;Myers et al. 2013). This suggested the possibility of frontal striatal abnormalities in AN patients. In a small study conducted in 2003, Lawrence et al. used a learning task sensitive to striatal function and a memory test sensitive to medial temporal lobe damage in a small group of AN patients tested while underweight. Foerde and Steinglass found this same pattern in their study after weight was regained.

Maladaptative behaviors may arise during development

If feedback learning is compromised in AN, how could this be related to the maladaptive behavior in AN? One answer, according to the authors, might be maladaptive behaviors established during a developmental “window” of learning in adolescence. Maladaptive eating behaviors and accelerated learning are most common during adolescence. Or, AN may affect neurocognitive processes so that developmental learning worsens the longer a person is ill, making it ever harder to counteract maladaptive behavior.

Decreased learning from feedback may also be important to the patient’s response to treatment. According to the authors, problems with feedback learning seen at baseline, without regard to how and when the behavior is acquired, and that are associated with failure to respond to treatment, could be a marker for a more chronic course of illness.

What Prompts Change in Younger Anorexia Nervosa Patients?

courtesy of eating disorders review

Measuring reasons for change among teens was not easy.

Two major roadblocks to change among patients with anorexia nervosa (AN) include ambivalence toward changing eating behaviors, and denial of the illness. Attempts to measure motivation to change among patients with eating disorders have led to development of instruments such as the Readiness and Motivation Interview (Int J Eat Disord. 2002; 46:755) and the Attitudes Towards Change in Eating Disorders Scale (ACTA) (Int J Eat Disord. 2000; 28:387; Acta Esp Psiquiatr. 2003; 31:111). A 20-item questionnaire, the Anorexia Nervosa Stages of Change Questionnaire (ANSOCQ), examines three key factors in motivation, weight gain, eating, shape and weight concerns, and ‘ego-alien aspects.’

Dr. Dagmar Paul and colleagues at the University Hospital of Psychiatry, Zurich, Switzerland, evaluated the German translation of the ANOSCQ among a Swiss-German sample of 92 teens with AN diagnosed by the International Classification of Diseases, Tenth Revision (ICD-10) criteria who were referred to the authors’ specialist eating disorders clinic. The researchers hypothesized that low coping capacity as well as low self-esteem could be linked to lower motivation to change patterns of disordered eating. The authors also explored whether motivation to change in AN patients is due to readiness to change, or if readiness to make changes should be regarded as only one of many other factors.

The mean body mass index (BMI, kg/m2) of the patient sample was 16.4 kg/m2, below the third percentile for age standards. The mean age of the 87 females and 9 males was 15.6 years; 84 had restricting type AN, while 8 had binge-purge type AN. All participants also were evaluated with the Eating Disorders Inventory (EDI-2), the Eating Attitudes Test (EAT), the Body Image Questionnaire (BIQ), the Self-related Cognitions Questionnaire, which measures self-esteem and self-awareness, and the Coping Across Situations Questionnaire (CASQ), which addresses coping in 4 problem areas: problems with school, parents, peers, and the opposite sex. Treatment outcome was defined as treatment satisfaction by the treating clinician, drop-out from treatment, and remission of AN (no longer fulfilling criteria for AN).

Changes at follow-up

At follow-up 9 months later, 66% of patients no longer met the criteria for AN, and of the remaining 30 patients, 20 had restrictive-type AN, 5 had binge-purge type AN, and 5 were diagnosed with atypical AN.

A negative correlation between ANOSCQ scores and BMI emerged: The authors’ findings indicated that BMI was inversely correlated to motivation to change, just as reported in earlier studies. Dr. Paul and his coauthors surmised that this might be due to the fact that young patients who are in the first phase of weight loss have not yet come face-to-face with the disadvantages of their illness, and thus are determined to lose even more weight. Their level of motivation to change is thus low. The study subjects had had AN for about 1 year; only 3.3% were in the action state, and none in the maintenance state. This finding contrasted with earlier studies, in which 20.5% of patients were in action or maintenance states.

The authors concluded that while the ANSOCQ questionnaire was valid and consistent, it might be less useful for young patients in the early stages of AN. The authors pointed out that younger patients at an early stage of an eating disorder are less aware of the negative consequences of the illness, and therefore “experience most of the symptoms as rather ego-syntonic or may ignore ego-dystonic aspects.” There is a need to assess motivation more systematically to enhance therapeutic strategies in younger patients.

The Effects of Compulsive Exercise among Teens

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A large longitudinal study targeted younger patients with EDs.

Information about the benefits of exercise abounds, including the many ways regular exercise can improve our health and life. Compulsive exercise, however, is a completely different matter, particularly for people with eating disorders. Approximately one in four teens with eating disorders uses compulsive exercise to lose weight or to improve appearance. A Swedish group recently examined whether teens show the same associations between compulsive exercise and problematic behaviors as do adults. In a second study, a British group analyzed a test for identifying compulsive exercise.

Does compulsive exercise differ in teens vs older groups?

Drs. Johanna Levallius, Christina Collin, and Andreas Birgegård, of Stockholm’s Karolinska Institute, evaluated how compulsive exercise relates to eating disorders diagnoses, symptoms, and outcome among teens. The authors hypothesized that patterns of compulsive exercise would be similar in teens and adults and also that such exercise would be associated with earlier onset of an ED, more symptoms, the presence of suicidality, negative perfectionism, hyperactivity, and overall poorer prognosis (J Eat Disord. 2017; 5:9 doi 10.1.1186/s40337-016-0129-8).

Using the Stepwise database, a nationwide Swedish clinical database of ED patients seeking treatment at specialized treatment centers, the authors identified 3,255 patients between 13 and 17 years of age, 95.7% of whom were girls. Age at onset of disease was defined from the patient’s own account of the first appearance of symptoms, and other data were collected from numerous questionnaires. This is the largest longitudinal study thus far to investigate the effect of compulsive exercise on adolescents with EDs.

The Eating Disorder Examination Questionnaire (EDEQ, adolescent version) provided information about denial of illness, and 31% of AN patients fell into this category. More than a third of the patients regularly used compulsive exercise (mean: 4 times a week) to moderate their weight. Patients with bulimia nervosa (BN) used compulsive exercise most often. Patients who compulsively exercised differed significantly from those who did not on several measures: restraint (as measured on the EDEQ), negative perfectionism, emotional distress, hyperactivity, and self-esteem. When “disease deniers” were taken out of the equation, the groups of non-compulsive and compulsive exercisers were much more similar. Compulsive exercise was not linked to increased risk of suicide.

At follow-up, the authors noted a degree of cross-over, so that most patients (69%) stopped using compulsive exercise as compensatory behavior. However, 17% of those who hadn’t used compulsive exercise before had now adopted the practice. Patients who stopped using compulsive exercise had a greater likelihood of remission compared to those who continued exercising compulsively.

Teenage boys: 1 in 3 used compulsive exercise

There were some data for teenage boys, too. Twenty-nine percent of the boys reported using compulsive exercise and did so for a mean of 4.1 times a week. As in the case of the girls, boys who compulsively exercised had significantly higher global EDEQ and restraint scores, and also reported more negative perfectionism, emotional distress, and hyperactivity than did the other boys. Depression affected 28% of the boys, and the prevalence was 41% among boys who used compulsive exercise. At the one-year follow-up point, 58% of the boys were in remission, and their initial use of compulsive exercise did not affect their prognosis.

For the girls, compulsive exercise was more common among those with BN and eating disorders not otherwise specified (EDNOS) than among those with AN. This was the same pattern seen in earlier studies of adult women (Int J Eat Disord. 2006; 39:45, Behav Res Ther. 2011; 49:85). Compared to studies of adults, adolescents who engaged in compulsive exercise did not have a worse prognosis than those who did not. At the one-year follow-up point, two-thirds of the teens who originally used compulsive exercise were no longer doing so, and the remission rate was similar for them as for teens who did not compulsively exercise (59% vs 56%, respectively).

The authors also cautioned against instructing ED patients to stop exercising–except during the acute phase of treatment. Instead, they suggested concentrating on teaching patients to eat and exercise for the right reasons.

Testing for compulsive exercise

Dr. Levallius and colleagues noted that while tests for CE have been largely lacking, British researchers have recently provided psychometric data on such a test, The Compulsive Exercise Test, among a group of 356 adult patients with EDs and 360 non-clinical controls (women 16 to 60 years of age). Patients and controls took the test and also completed the EDE-Q (J Eat Disord. 2016;4:22). Caroline Meyer, MD, and colleagues at the University of Warwick, Coventry, UK, noted that up to 85% of patients with disordered eating use compulsive exercise, and are unable to stop the practice despite understanding the possible consequences.

The Compulsive Exercise Test contains 24 self-report items designed to assess the cognitive, behavioral, and emotional features of compulsive exercise. A previous factor analysis yielded five subscales: avoidance and rule-driven behavior, weight control exercise, mood improvement, lack of exercise enjoyment, and exercise rigidity (Taronis et al, 2011). The current paper described efforts to confirm this factor structure and to look at the relationship of scores to ED psychopathology.

Among the study group, 25.9% of patients had AN, 31% had BN, 38% were diagnosed with EDNOS, and 5% had diagnoses of BED. The control group was recruited from a university campus, workplaces, and a sports club. Elite or sub-elite athletes were excluded. The authors reported that the clinical group scored significantly higher than the non-clinical group on 4 of the 5 main subscales and had significantly higher global scores. However, the mood improvement subscale scores did not differ, and there were no significant differences by age.

Dr. Meyer and colleagues note that while much more research on the CET is needed, the fact that excessive or driven exercise often predates the onset of an eating disorder suggests the CET might be a way to identify individuals at risk of developing an eating disorder.

Defining Compulsive Exercise

Compulsive exercise (also termed problematic exercise) describes a condition of weight and shape concern and a persistent continuation of exercise in order to: (a) mitigate guilt/negative affect if not exercising, and (b) to avoid perceived negative consequences of ‘stopping’ exercise (Eur Eat Disord Rev. 2011; 19:174).

Bone Loss Risk across the Anorexia Nervosa Spectrum

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Higher current weight does not protect against a history of extreme food restriction.

Bone density (BMD) impairment and comorbid psychopathology can affect women on all points of the anorexia nervosa (AN) spectrum, not just those who are currently underweight and/or amenorrheic, according to the results of a recent study (Int J Eat Disord. 2017; 50:343).

Compared to the DSM-IV, the DSM-5 has relaxed some of the diagnostic criteria for AN. For example, the newer diagnostic criteria eliminate the requirement for amenorrhea, and loosen weight and psychological criteria. In addition, the guidelines add a new diagnosis of “atypical AN” for persons with psychological symptoms of AN but who aren’t at lower-than-normal weights.

Dr. Melanie Schorr and a group at the Massachusetts General Hospital and Harvard Medical School recently investigated if and how BMD is affected among women diagnosed with AN by the DSM-5, including those in the new category of atypical AN. This is the first study to directly compare bone density among groups all across the AN diagnostic spectrum and healthy controls.

The researchers studied 4 groups of premenopausal women ranging from 18 to 45 years of age: (1) 37 with diagnoses of AN from DSM-IV criteria but not DSM-5 criteria (DSM-IV AN group); (2) 33 with AN diagnosed with DSM-5 but not DSM-IV criteria (DSM-5 group); (3) 77 women with atypical AN (atypical AN group); and a comparison group of 21 healthy women (HC group). BMD and body composition were assessed for all the women through dual-energy x-ray absorptiometry (DXA) scans. Posteroanterior (PA) spine BMD, measured from lumbar vertebrae 1 through 4, was available for 166 of the 168 participants, and lateral spine BMD of the same 4 vertebrae was measured for 106 women. In addition, eating disorder psychopathology was assessed with a number of questionnaires, including the Eating Disorder Examination-Questionnaire (EDE-Q).

Higher weight and restoration of menses do not guarantee healthy BMD.

The authors also reported significant differences in body composition among the 4 groups. Mean percent fat mass was similarly low in women with DSM-IV and DSM-5 diagnoses of AN, higher in those with atypical AN, and highest in healthy women. As BMI falls, as was shown in all 4 groups, there was a concurrent loss of lean muscle mass as well because of extreme food restriction. Loss of lean muscle mass may also contribute to low BMD, according to the authors.

The authors’ data suggest that severe impairment of BMD can occur even among individuals at higher weights and those who have normal or regular menstrual periods. They also report that women with DSM-5 diagnoses of AN, even those at normal weights, and especially those with a history of low weight and/or amenorrhea, showed evidence of significant bone loss when compared with normal women. Even when they weren’t underweight, women with atypical AN and a history of low weight and/or amenorrhea had significantly lower mean PA spine BMD z-scores than did healthy women. Thus, being at a higher weight does not protect a former AN patient from low BMD when he or she has a history of low weight and/or amenorrhea.

Better understanding might be a motivating factor.

This is an important study for several reasons. First, Dr. Schorr and colleagues note that when patients understand that pathological food restriction can lead to loss of lean mass, not just fat mass, it may be motivation for change. This is especially true for women who fear they will only “get fat” as their weight is restored. Second, women with significant psychopathology and low body fat, low-weight women with DSM-5 diagnoses of AN, and normal-weight women with atypical AN and a history of low weight and/or amenorrhea are all candidates for DXA scanning. Third, this underscores the idea that in eating disorders, subthreshold does not equate to less severe.