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This Article will focus on: 

• What are Eating Disorders?
• Causes and Vulnerability to ED
• Eating Disorders in Men and LGBTQ+ Community

What are Eating Disorders? 

At a clinical level, Eating Disorders are defined as “a persistent disturbance of feeding or eating-related behaviour that results in the altered consumption or absorption of food and significantly impairs physical health or psychosocial functioning” [1]. Truth is it is hard to limit the infinitely multifaceted nature of these disorders to a plain scientific definition.

To this day, there are six clinically diagnosable eating disorders. Below are extracts from the DSM-5[1], the manual of clinical disorders, which help understand what these disorders entail:

These criteria are mutually exclusive, hence one episode (3 month period) cannot be simultaneously bulimic and anorexic, for example. Still, it is extremely common for the same individual to go through different EDs within a life-span.

There are a few misconceptions related to eating disorders:

• The first is that Anorexia Nervosa is the most common and only dangerous eating disorder. However, not many of us know that Bulimia Nervosa (BN) and the Binge-eating disorder (BED) are far more common, affecting respectively 1.5% and 1.6% of the world-wide female population respectively.  Anorexia does have the highest mortality rates (5% of the world per decade) but this does not make the other disorders less dangerous[2].
• Secondly, people often believe that a specific weight or body mass index (BMI) is required to classify as Anorexic. However, weight has been removed from the latest version of DSM as it is not to be deemed to be relevant in diagnosis. However, BMI is still used to specify the severity of anorexia (e.g., it is considered extreme below 15 kg/m2 BMI)[2]
• It is common to classify obesity as an eating disorder. However, obesity is related to genetic, physical, behavioural and environmental factors and it is not to be considered an eating disorder per se. However, obesity is often a consequence of BED [1].
• "Once you have an eating disorder you will always have one". This is not only untrue but also a very dangerous statement as it can bring people suffering from an ED to a state of hopelessness. Eating disorders can be treated and a lot of people have been able to live a normal, healthy, and peaceful life once they healed.

Causes and Vulnerability

Eating disorders are highly personal and tied to infinite dimensions of a person, ranging from topics of control, to identity, to self-esteem. They can also act as coping mechanisms or be helpful in the suppressions of emotions. For this reason it is hard to pin-point some specific causes, however, here are some factors that seem to play a role in the development of EDs.

Personality

Recent research has focused a lot on the role of personality traits and how some of them may increase the vulnerability to eating disorders[4].

One trait that has gained significant attention is perfectionism. Perfectionism is multifaceted and not all of the dimensions are correlated to EDs. Specifically, neurotic perfectionism, characterised by high levels of preoccupation of mistakes and heightened anxiety in relation to performance, has been seen to be more related to EDs than normal perfectionism (i.e., setting high standards for oneself without being over concerned). Moreover, self-oriented perfectionism and socially-prescribed perfectionism (i.e., believing that others will be harshly critical of you, wanting to be perfect in their eyes) tend to be associated with the restrictive type of Anorexia, Bulimia and BED. It is still unclear, however, whether these types of perfectionism are directly correlated with the development of EDs or to a general level of maladjustment which may in turn trigger these disorders [4]. To find more about perfectionism take a look at this article we wrote.

Moreover, highly compulsive and impulsive traits also seem to play a role. Compulsiveness is characterised by the need to engage in restrictive and repetitive behaviours, usually as a consequence of obsessive thoughts. This trait is highly related to the restrictive type of anorexia. Suffering from the Obsessive Compulsive Disorder (OCD) in childhood can, in fact, be a predictor of AN in adolescence. To find more about OCD take a look at this article we wrote. On the other hand, impulsivity is related to BN and BED. People often engage in binging and purging behaviours without forethought or contemplation of the risks and consequences of the behaviour (i.e., health risks and increased dysphoria). Similarly, high sensation seeking (willingness for new, complex, risky experiences) can also predispose people to bingeing and purging behaviours. Impulsivity, however, is more a state like characteristic that comes with the disordered eating rather than a dispositional trait and when people recover from their ED they tend to show decreased levels of impulsivity as well [4].

At pathological levels, Narcissism is more often comorbid with AN and BN than other psychiatric disorders, indicating it could be a potential risk factor. The excessive concern for appearance, external appreciation and fragile self-esteem can be potential triggers of EDs[4].

Lastly, sociotropic-orientedness (high value for acceptance and approval in their interpersonal relationships) as opposed to autonomy-orientedness (high value for independence and achievement) is more frequently associated with EDs. In particular, an inner conflict between will for autonomy and sociotropic tendencies are seen to be a potential triggering factor. However, this relationship is usually mediated by low levels of self-esteem [4].  

All in all, personality factors can increase vulnerabilities for these disorders but are not alone to be considered causal factors, as they usually interplay with infinite other personal and environmental dynamics.

Affect Regulation  

The role of eating disorders in emotion regulation has received widespread consensus in recent years. A meta-analysis conducted by Stice (2002) concluded that negative affect was a strong predictor of disordered eating, indicating that such behaviours can act as coping mechanisms for negative feelings[6]. In particular, binge-eating and overeating may reduce the active awareness of distress. In many occasions it is much simpler to focus on the immediate gratification of food than to be in pain. Similarly, physical activity can be extremely stress-relieving for some people. Although, physical activity per se is not necessarily maladaptive it is important that it does not become excessive or the only coping strategy of the individual[8].

Therapeutic techniques such as the Dialectical Behavioural Treatment (DBT) focus on teaching more adaptive coping strategies to people with eating disorders in order to help them deal with pain and distress in a healthier manner[5].

Interpersonal Difficulties

From the times of historical psychologists, such as Meyer, Sullivan and Bowlby, interpersonal functioning has been recognised as an essential component of general well-being. There is a proper two-way relationship between interpersonal difficulties and psychopathology:  difficulties in social roles can act as antecedents for mental illnesses AND mental illnesses can significantly impair social roles[3].

In specific to EDs, issues with social functioning can lead to difficulties with self-esteem and negative affect which can in turn increase vulnerabilities to ED[3].  

There are four domains of interpersonal difficulties that seem to impact the development of EDs:

1) Interpersonal deficits:  social isolation or being in chronic, unfulfilling relationships. Having inadequate social support or lacking the skills to interrelate to others properly.
2) Interpersonal role disputes: conflicts with significant others. These usually emerge because in differences of expectations between parties (e.g. partners, parents).
3) Role transitions: difficulties associated with change, sudden life status changes.
4) Grief:  recent loss of person, relationship, past role are also associated with symptoms[3].

Moreover, EDs have been seen to be particularly related to interpersonal problem-solving difficulties, negative attitudes toward emotional expression and fear of intimacy[3].

Eating Disorders in Men and LGBTQ+ Community

Eating Disorders are generally perceived solely as a female problem. While it is true that Bulimia and Anorexia are extremely more prevalent in females than males (with a ratio of 10:1), this cannot be said about BED which is nearly equally present in both genders. Also, due to the deep stigma surrounding body image issues in men it is very likely for theeir EDs to get under-diagnosed, under-treated or misunderstood[7]. The last 30 years have been characterised by an exponential increase in media pressure on body image, focusing on muscularity and unrealistic body ideals even for males. This has brought men to report higher levels of depression and body dissatisfaction compared to the past, ultimately increasing their vulnerability to EDs[7].

Eating disorders in men often take different forms from those female EDs. For example, they tend to engage in excessive exercise and fall into vicious cycles of exercising and dieting more frequently than females. This behavioural pattern can become addictive and is known as Anorexia Athleticism. Similarly, men are prone to suffer from Muscle Dysmorphia, an excessive focus on muscle mass and body size, which is usually associated with EDs[7].  

One of the strongest predictor of EDs in men is weight history. Men who have been moderately obese or fat in the past are more prone to developing an ED, especially if this occurred during childhood[7].

LGBTQ+ Community

Gay and bisexual men are ten times more likely than heterosexual men to develop an eating disorder. The reason behind this discrepancy is yet unclear, however, it is important to note that homosexuality itself is not predictive of EDs but may increase their vulnerability. Some studies suggest that people struggling with their sexual orientation may engage in disordered eating because it significantly decreases their sexual libido and hence reliefs their distress. Moreover, a few studies suggested that EDs tend to be more prevalent in undifferentiated and feminine gender roles than masculine ones due to higher societal pressures of the thinness-ideal[7].

In conclusion,

Eating disorders are an extremely relevant reality. Understanding the nature and potential vulnerabilities of these disorders is essential for early intervention. This article only sheds light upon some of the causes of EDs but it is far more complex than this and we will certainly try to dig deeper into their intricacies in future articles.

As a final note we would like to underline that establishing a proper diet and being in the "healthy" weight range is not enough to consider one healed from an Eating Disorder. EDs are a mental illness and as such they can only be treated by professionals. We hence stress the importance of reaching out for help to mental health services.

References

1. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (DSM-5®). American Psychiatric Pub. https://doi-org.eur.idm.oclc.org/10.1176/appi.books.9780890425596.dsm10
2. ANAD Eating Disorder Statistics. Retrieved from: https://anad.org/get-informed/about-eating-disorders/eating-disorders-statistics/
3. Burke, N. L., Karam, A. M., Tanofsky-Kraff, M., & Wilfley, D. E. (2018). Interpersonal psychotherapy for the treatment of eating disorders.
4. Cassin, S. E., & von Ranson, K. M. (2005). Personality and eating disorders: a decade in review. Clinical psychology review, 25(7), 895-916. https://doi.org/10.1016/j.cpr.2005.04.012
5. Chen, E. Y., Matthews, L., Allen, C., Kuo, J. R., & Linehan, M. M. (2008). Dialectical behavior therapy for clients with binge‐eating disorder or bulimia nervosa and borderline personality disorder. International Journal of Eating Disorders, 41(6), 505-512.
6. Stice E,Agras WS. Subtyping bulimic women along dietary restraint and negative affect dimensions. J Consult Clin Psychol 1999; 67: 460–469.
7. Strother, E., Lemberg, R., Stanford, S. C., & Turberville, D. (2012). Eating disorders in men: underdiagnosed, undertreated, and misunderstood. Eating disorders, 20(5), 346-355. https://doi.org/10.1080/10640266.2012.715512
8. Vansteelandt, K., Rijmen, F., Pieters, G., Probst, M., & Vanderlinden, J. (2007). Drive for thinness, affect regulation and physical activity in eating disorders: A daily life study. Behaviour Research and Therapy, 45(8), 1717-1734. https://doi.org/10.1016/j.brat.2006.12.005