The Stigma is Real: Self-Blame and Explanations for Eating Disorders

Stigma is a real thing. There you go, the most profound statement I’ve ever written. In all seriousness though, there’s a big stigma problem around eating disorders, and not all of it is imposed from the outside. Many people with eating disorders also self-stigmatize, feeling responsible for their disorder (Holliday, Wall, Treasure & Weinman, 2005 wrote more about this). Other stigma is externally imposed; for instance, the widely held (and erroneous) belief that eating disorders are only something vain young girls get or that they are a choice.

Stigma around eating disorders sometimes differs betweens diagnoses, and especially between eating disorders and other mental illnesses – for instance, Roehrig and McLean (2010) found that eating disorders (both anorexia nervosa and bulimia nervosa) were more stigmatized than depression, and that eating disorder stigma uniquely (and horribly) included a certain degree of envy. The stigma associated with AN is commonly tied up in a perception of AN as being about getting attention or as a choice (Stewart, Keel & Schiavo, 2006). People often seem to think they “know” what AN is like; BN, on the other hand, is arguably even less understood, and a lack of knowledge about BN may contribute to increased stigma (Rodgers et al., 2015).

It’s also interesting, if distressing, to look at stigma and stereotypes around eating disorders from a cultural perspective. Because stigma may make people hesitant to seek help, how might stigma exacerbate existing barriers to care amongst people who don’t fit the expected stereotype of what an eating disorder looks like?

Plenty of studies outside of the eating disorder-specific realm are oriented toward looking at how mental illness is viewed more negatively in certain cultures, or as something you would never discuss outside of the family for fear of losing face. Surprisingly few studies within the eating disorder field parse stigma out into an exploration of how it differently impacts people from various social locations (i.e., people in larger bodies, people of colour, people of various genders, sexualities, etc.).

However, this post is not about cultural differences in stigma – largely because I couldn’t find any good articles about that (so I’ll probably have to just do that research at some point). This post is about another fascinating and relevant debate about stigma: whether seeing eating disorders as a psychological or biological illness is more helpful for alleviating stigma (see also this post by Tetyana on another of my favourite articles for more on that).

The Study

Farrell, Lee and Deacon (2015) looked at the impact of different explanations of eating disorders (as psychological or biological) on people with eating disorders in terms of how much they blamed themselves for their disorders and whether they expected to recover. Others have looked at whether psychological or biological framing is less stigmatizing (Crisfallui, Von Holle & Bulik, 2008 is often cited in this area).

Looking at self-stigma is particularly important, Farrell and colleagues note, because while biological explanations might help others understand that eating disorders are not a matter of choice, they could potentially make people with eating disorders see recovery as impossible (i.e., that genetics mean that eating disorders are set in stone and there is nothing they can do about it). I have certainly heard people make this argument, so this is a major part of what I found interesting about this study.

The researchers recruited 216 participants in the US who scored above the cut off on the Eating Disorder Examination Questionnaire (EDE-Q, global, or overall, scale) and who had never received treatment for their eating disorder. Most participants were women (76.9%) and most were Caucasian (74.5%), though this is still a slightly more diverse sample than many eating disorder studies. Most participants had never been diagnosed with an eating disorder.

Participants completed a modified version of a scale called the Attitudes Toward Eating Disorder Symptoms (AEDS) scale; the authors altered the scale to assess whether people blame themselves for their symptoms. They also used the Credibility/Expectancy Questionnaire (CEQ) to look for how willing participants would be to seek different types of treatment (such as CBT) and how much they assumed these kinds of therapy would help.

Those involved in the study participated in a psychoeducational program that presented eating disorders as an illness rooted in:

• Biology
• Biological-environmental interaction
• Cognitive-behavioural factors like body image, restriction, etc.

The authors found: 

• That those in the biological illness group were significantly more likely to see eating disorder symptoms as unalterable than did those in the cognitive behavioural group
• Perhaps predictably, given the first point, those in the biological illness group were also less likely to see themselves as in control over their symptoms and to feel able to tackle them
• There were only minimal differences between the groups in terms of how likely recovery seemed to participants
• Not at all surprisingly, those who participated in cognitive behavioural psychoeducation also saw cognitive behavioural treatment as likely to help them recover

So, What Does This Mean?

The authors suggest that their results demonstrate the importance of ensuring that any biologically-focused eating disorder psychoeducation highlight that biology does not mean the illness is set in stone. However, keep in mind that they did not actually find that there were major differences between the psychoeducation types when looking at self-blame for eating disorders in general. Their results are certainly interesting; they show that there may be a link between solely biological framings and feeling unable to control symptoms.

However, in my view there isn’t really enough here to support the conclusion that mutable biology psychoeducation actually reduces self-blame. Do I think it is a good idea to present eating disorders as a mix of biological and psychological factors? Of course – as I’ve noted many times before, I think presenting eating disorders as borne of only one or the other is not a good idea as it reduces the complexity of eating disorders to an either/or question and makes it seem like people grow up in petri dishes. But the results here point mainly to differences between purely biological and purely psychological explanations; they did not find many significant results specifically related to the mutable biology condition.

I also think we need to look at more than just cognitive behavioural treatment when looking at ways of altering symptoms. Yes, CBT has been shown to be relatively effective (comparatively); but, rather obviously, there are many different types of treatments for eating disorders. Is it possible that understanding eating disorders as caused by biology, psychology, or both impacts what type of treatment one might see as helpful?

I also think it is interesting that in many, many studies, biology and psychology are binarized at all. After all, the brain is a part of the body. To pretend like it is not isn’t just bad science – it’s illogical. Any scientist (“hard scientist” or social scientist alike) worth their salt will note that there’s a lot of co-influence between things traditionally presented as “of the body” and as environment. This is more a general commentary than a critique of this study in particular, but something that continues to irk me.

Lastly, as interesting as this study is, it only partially addresses the question of stigma, which as the authors acknowledge is complex and significant to eating disorders. Looking at self-stigma is of course important, and this study adds to the body of literature on stigma and eating disorders. What I’m really itching for, though, are studies that delve more deeply into how stigma shifts and morphs not only due to perceptions about what causes eating disorders but also in light of people’s social spaces of belonging.

Reference

Farrell, N. R., Lee, A. A., & Deacon, B. J. (2015). Biological or psychological? Effects of eating disorder psychoeducation on self-blame and recovery expectations among symptomatic individuals. Behaviour Research and Therapy, 74, 32-7 PMID: 26378721