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What is Family Therapy?

Published on by Andrew Marshall3 Comments

Introduction

Family therapy, also referred to as couple and family therapy, marriage and family therapy, family systems therapy, and family counselling, is a branch of psychotherapy that works with families and couples in intimate relationships to nurture change and development. It tends to view change in terms of the systems of interaction between family members.

The different schools of family therapy have in common a belief that, regardless of the origin of the problem, and regardless of whether the clients consider it an “individual” or “family” issue, involving families in solutions often benefits clients. This involvement of families is commonly accomplished by their direct participation in the therapy session. The skills of the family therapist thus include the ability to influence conversations in a way that catalyses the strengths, wisdom, and support of the wider system.

In the field’s early years, many clinicians defined the family in a narrow, traditional manner usually including parents and children. As the field has evolved, the concept of the family is more commonly defined in terms of strongly supportive, long-term roles and relationships between people who may or may not be related by blood or marriage.

The conceptual frameworks developed by family therapists, especially those of family systems theorists, have been applied to a wide range of human behaviour, including organisational dynamics and the study of greatness.

Brief History and Theoretical Frameworks

Formal interventions with families to help individuals and families experiencing various kinds of problems have been a part of many cultures, probably throughout history. These interventions have sometimes involved formal procedures or rituals, and often included the extended family as well as non-kin members of the community (see for example Ho’oponopono). Following the emergence of specialisation in various societies, these interventions were often conducted by particular members of a community – for example, a chief, priest, physician, and so on – usually as an ancillary function.

Family therapy as a distinct professional practice within Western cultures can be argued to have had its origins in the social work movements of the 19th century in the United Kingdom and the United States. As a branch of psychotherapy, its roots can be traced somewhat later to the early 20th century with the emergence of the child guidance movement and marriage counselling. The formal development of family therapy dates from the 1940s and early 1950s with the founding in 1942 of the American Association of Marriage Counsellors (the precursor of the AAMFT), and through the work of various independent clinicians and groups – in the United Kingdom (John Bowlby at the Tavistock Clinic), the United States (Donald deAvila Jackson, John Elderkin Bell, Nathan Ackerman, Christian Midelfort, Theodore Lidz, Lyman Wynne, Murray Bowen, Carl Whitaker, Virginia Satir, Ivan Boszormenyi-Nagy), and in Hungary, D.L.P. Liebermann – who began seeing family members together for observation or therapy sessions. There was initially a strong influence from psychoanalysis (most of the early founders of the field had psychoanalytic backgrounds) and social psychiatry, and later from learning theory and behaviour therapy – and significantly, these clinicians began to articulate various theories about the nature and functioning of the family as an entity that was more than a mere aggregation of individuals.

The movement received an important boost starting in the early 1950s through the work of anthropologist Gregory Bateson and colleagues – Jay Haley, Donald D. Jackson, John Weakland, William Fry, and later, Virginia Satir, Ivan Boszormenyi-Nagy, Paul Watzlawick and others – at Palo Alto in the United States, who introduced ideas from cybernetics and general systems theory into social psychology and psychotherapy, focusing in particular on the role of communication (refer to Bateson Project). This approach eschewed the traditional focus on individual psychology and historical factors – that involve so-called linear causation and content – and emphasized instead feedback and homeostatic mechanisms and “rules” in here-and-now interactions – so-called circular causation and process – that were thought to maintain or exacerbate problems, whatever the original cause(s). This group was also influenced significantly by the work of US psychiatrist, hypnotherapist, and brief therapist, Milton H. Erickson – especially his innovative use of strategies for change, such as paradoxical directives. The members of the Bateson Project (like the founders of a number of other schools of family therapy, including Carl Whitaker, Murray Bowen, and Ivan Boszormenyi-Nagy) had a particular interest in the possible psychosocial causes and treatment of schizophrenia, especially in terms of the putative “meaning” and “function” of signs and symptoms within the family system. The research of psychiatrists and psychoanalysts Lyman Wynne and Theodore Lidz on communication deviance and roles (e.g. pseudo-mutuality, pseudo-hostility, schism and skew) in families of people with schizophrenia also became influential with systems-communications-oriented theorists and therapists. A related theme, applying to dysfunction and psychopathology more generally, was that of the “identified patient” or “presenting problem” as a manifestation of or surrogate for the family’s, or even society’s, problems (refer to Double Bind).

By the mid-1960s, a number of distinct schools of family therapy had emerged. From those groups that were most strongly influenced by cybernetics and systems theory, there came MRI Brief Therapy, and slightly later, strategic therapy, Salvador Minuchin’s Structural Family Therapy and the Milan systems model. Partly in reaction to some aspects of these systemic models, came the experiential approaches of Virginia Satir and Carl Whitaker, which downplayed theoretical constructs, and emphasized subjective experience and unexpressed feelings (including the subconscious), authentic communication, spontaneity, creativity, total therapist engagement, and often included the extended family. Concurrently and somewhat independently, there emerged the various intergenerational therapies of Murray Bowen, Ivan Boszormenyi-Nagy, James Framo, and Norman Paul, which present different theories about the intergenerational transmission of health and dysfunction, but which all deal usually with at least three generations of a family (in person or conceptually), either directly in therapy sessions, or via “homework”, “journeys home”, etc. Psychodynamic family therapy – which, more than any other school of family therapy, deals directly with individual psychology and the unconscious in the context of current relationships – continued to develop through a number of groups that were influenced by the ideas and methods of Nathan Ackerman, and also by the British School of Object Relations and John Bowlby’s work on attachment. Multiple-family group therapy, a precursor of psychoeducational family intervention, emerged, in part, as a pragmatic alternative form of intervention – especially as an adjunct to the treatment of serious mental disorders with a significant biological basis, such as schizophrenia – and represented something of a conceptual challenge to some of the “systemic” (and thus potentially “family-blaming”) paradigms of pathogenesis that were implicit in many of the dominant models of family therapy. The late-1960s and early-1970s saw the development of network therapy (which bears some resemblance to traditional practices such as Ho’oponopono) by Ross Speck and Carolyn Attneave, and the emergence of behavioural marital therapy (renamed behavioural couples therapy in the 1990s; see also relationship counselling) and behavioural family therapy as models in their own right.

By the late-1970s, the weight of clinical experience – especially in relation to the treatment of serious mental disorders – had led to some revision of a number of the original models and a moderation of some of the earlier stridency and theoretical purism. There were the beginnings of a general softening of the strict demarcations between schools, with moves toward rapprochement, integration, and eclecticism – although there was, nevertheless, some hardening of positions within some schools. These trends were reflected in and influenced by lively debates within the field and critiques from various sources, including feminism and post-modernism, that reflected in part the cultural and political tenor of the times, and which foreshadowed the emergence (in the 1980s and 1990s) of the various “post-systems” constructivist and social constructionist approaches. While there was still debate within the field about whether, or to what degree, the systemic-constructivist and medical-biological paradigms were necessarily antithetical to each other (refer to Anti-psychiatry; Biopsychosocial model), there was a growing willingness and tendency on the part of family therapists to work in multi-modal clinical partnerships with other members of the helping and medical professions.

From the mid-1980s to the present, the field has been marked by a diversity of approaches that partly reflect the original schools, but which also draw on other theories and methods from individual psychotherapy and elsewhere – these approaches and sources include: brief therapy, structural therapy, constructivist approaches (e.g. Milan systems, post-Milan/collaborative/conversational, reflective), Bring forthism approach (e.g. Dr. Karl Tomm’s IPscope model and Interventive interviewing), solution-focused therapy, narrative therapy, a range of cognitive and behavioural approaches, psychodynamic and object relations approaches, attachment and emotionally focused therapy, intergenerational approaches, network therapy, and multi-systemic therapy (MST). Multicultural, intercultural, and integrative approaches are being developed, with Vincenzo Di Nicola weaving a synthesis of family therapy and transcultural psychiatry in his model of cultural family therapy, A Stranger in the Family: Culture, Families, and Therapy. Many practitioners claim to be “eclectic”, using techniques from several areas, depending upon their own inclinations and/or the needs of the client(s), and there is a growing movement toward a single “generic” family therapy that seeks to incorporate the best of the accumulated knowledge in the field and which can be adapted to many different contexts; however, there are still a significant number of therapists who adhere more or less strictly to a particular, or limited number of, approach(es).

The Liberation Based Healing framework for family therapy offers a complete paradigm shift for working with families while addressing the intersections of race, class, gender identity, sexual orientation and other socio-political identity markers. This theoretical approach and praxis is informed by Critical Pedagogy, Feminism, Critical Race Theory, and Decolonising Theory. This framework necessitates an understanding of the ways Colonisation, Cis-Heteronormativity, Patriarchy, White Supremacy and other systems of domination impact individuals, families and communities and centres the need to disrupt the status quo in how power operates. Traditional Western models of family therapy have historically ignored these dimensions and when white, male privilege has been critiqued, largely by feminist theory practitioners, it has often been to the benefit of middle class, white women’s experiences. While an understanding of intersectionality is of particular significance in working with families with violence, a liberatory framework examines how power, privilege and oppression operate within and across all relationships. Liberatory practices are based on the principles of Critical-Consciousness, Accountability and Empowerment. These principles guide not only the content of the therapeutic work with clients but also the supervisory and training process of therapists. Dr. Rhea Almeida, developed the Cultural Context Model as a way to operationalize these concepts into practice through the integration of culture circles, sponsors, and a socio-educational process within the therapeutic work.

Ideas and methods from family therapy have been influential in psychotherapy generally: a survey of over 2,500 US therapists in 2006 revealed that of the 10 most influential therapists of the previous quarter-century, three were prominent family therapists and that the marital and family systems model was the second most utilised model after cognitive behavioural therapy.

Techniques

Family therapy uses a range of counselling and other techniques including:

  • Structural therapy – identifies and re-orders the organisation of the family system.
  • Strategic therapy – looks at patterns of interactions between family members.
  • Systemic/Milan therapy – focuses on belief systems.
  • Narrative therapy – restoring of dominant problem-saturated narrative, emphasis on context, separation of the problem from the person.
  • Transgenerational therapy – transgenerational transmission of unhelpful patterns of belief and behaviour.
  • IPscope model and Interventive Interviewing.
  • Communication theory.
  • Psychoeducation.
  • Psychotherapy.
  • Relationship counselling.
  • Relationship education.
  • Systemic coaching.
  • Systems theory.
  • Reality therapy.
  • The genogram.

The number of sessions depends on the situation, but the average is 5-20 sessions. A family therapist usually meets several members of the family at the same time. This has the advantage of making differences between the ways family members perceive mutual relations as well as interaction patterns in the session apparent both for the therapist and the family. These patterns frequently mirror habitual interaction patterns at home, even though the therapist is now incorporated into the family system. Therapy interventions usually focus on relationship patterns rather than on analysing impulses of the unconscious mind or early childhood trauma of individuals as a Freudian therapist would do – although some schools of family therapy, for example psychodynamic and intergenerational, do consider such individual and historical factors (thus embracing both linear and circular causation) and they may use instruments such as the genogram to help to elucidate the patterns of relationship across generations.

The distinctive feature of family therapy is its perspective and analytical framework rather than the number of people present at a therapy session. Specifically, family therapists are relational therapists: They are generally more interested in what goes on between individuals rather than within one or more individuals, although some family therapists – in particular those who identify as psychodynamic, object relations, intergenerational, or experiential family therapists (EFTs) – tend to be as interested in individuals as in the systems those individuals and their relationships constitute. Depending on the conflicts at issue and the progress of therapy to date, a therapist may focus on analysing specific previous instances of conflict, as by reviewing a past incident and suggesting alternative ways family members might have responded to one another during it, or instead proceed directly to addressing the sources of conflict at a more abstract level, as by pointing out patterns of interaction that the family might have not noticed.

Family therapists tend to be more interested in the maintenance and/or solving of problems rather than in trying to identify a single cause. Some families may perceive cause-effect analyses as attempts to allocate blame to one or more individuals, with the effect that for many families a focus on causation is of little or no clinical utility. It is important to note that a circular way of problem evaluation is used as opposed to a linear route. Using this method, families can be helped by finding patterns of behaviour, what the causes are, and what can be done to better their situation.

Summary of Theories and Techniques

Theoretical ModelTheoristsSummaryTechniques
Adlerian family therapyAlfred AdlerAlso known as “individual psychology”. Sees the person as a whole. Ideas include compensation for feelings of inferiority leading to striving for significance toward a fictional final goal with a private logic. Birth order and mistaken goals are explored to examine mistaken motivations of children and adults in the family constellation.Psychoanalysis, typical day, reorienting, re-educating
Attachment theoryJohn Bowlby, Mary Ainsworth, Douglas HaldaneIndividuals are shaped by their experiences with caregivers in the first three years of life. Used as a foundation for Object Relations Theory. The Strange Situation experiment with infants involves a systematic process of leaving a child alone in a room in order to assess the quality of their parental bond.Psychoanalysis, play therapy
Bowenian family systems therapyMurray Bowen, Betty Carter, Philip Guerin, Michael Kerr, Thomas Fogarty, Monica McGoldrick, Edwin Friedman, Daniel PaperoAlso known as “intergenerational family therapy” (although there are also other schools of intergenerational family therapy). Family members are driven to achieve a balance of internal and external differentiation, causing anxiety, triangulation, and emotional cutoff. Families are affected by nuclear family emotional processes, sibling positions and multigenerational transmission patterns resulting in an undifferentiated family ego mass.Detriangulation, non-anxious presence, genograms, coaching
Cognitive behavioural family therapyJohn Gottman, Albert Ellis, Albert BanduraProblems are the result of operant conditioning that reinforces negative behaviours within the family’s interpersonal social exchanges that extinguish desired behaviour and promote incentives toward unwanted behaviours. This can lead to irrational beliefs and a faulty family schema.Therapeutic contracts, modelling, systematic desensitisation, shaping, charting, examining irrational beliefs
Collaborative language systems therapyHarry Goolishian, Harlene Anderson, Tom Andersen, Lynn Hoffman, Peggy PennIndividuals form meanings about their experiences within the context of social relationship on a personal and organisational level. Collaborative therapists help families reorganise and dis-solve their perceived problems through a transparent dialogue about inner thoughts with a “not-knowing” stance intended to illicit new meaning through conversation. Collaborative therapy is an approach that avoids a particular theoretical perspective in favour of a client-centred philosophical process.Dialogical conversation, not knowing, curiosity, being public, reflecting teams
Communications approachesVirginia Satir, John Banmen, Jane Gerber, Maria GomoriAll people are born into a primary survival triad between themselves and their parents where they adopt survival stances to protect their self-worth from threats communicated by words and behaviours of their family members. Experiential therapists are interested in altering the overt and covert messages between family members that affect their body, mind and feelings in order to promote congruence and to validate each person’s inherent self-worth.Equality, modelling communication, family life chronology, family sculpting, metaphors, family reconstruction
Contextual therapyIvan Boszormenyi-NagyFamilies are built upon an unconscious network of implicit loyalties between parents and children that can be damaged when these “relational ethics” of fairness, trust, entitlement, mutuality and merit are breached.Rebalancing, family negotiations, validation, filial debt repayment
Cultural family therapyVincenzo Di Nicola
Key influences: Celia Falicov, Antonio Ferreira, James Framo, Edwin Friedman, Mara Selvini Palazzoli, Carlos Sluzki, Victor Turner, Michael White		A synthesis of systemic family therapy with cultural psychiatry to create cultural family therapy (CFT). CFT is an interweaving of stories (family predicaments expressed in narratives of family life) and tools (clinical methods for working with and making sense of these stories in cultural context). Integrates and synthesizes systemic therapy and cultural and medical anthropology with narrative therapy.Conceptual tools for working across cultures – spirals, masks, roles, codes, cultural strategies, bridges, stories, multiple codes (metaphor and somatics), therapy as “story repair”
Emotion-focused therapySue Johnson, Les GreenbergCouples and families can develop rigid patterns of interaction based on powerful emotional experiences that hinder emotional engagement and trust. Treatment aims to enhance empathic capabilities of family members by exploring deep-seated habits and modifying emotional cues.Reflecting, validation, heightening, reframing, restructuring
Experiential family therapyCarl Whitaker, David Keith, Laura Roberto, Walter Kempler, John Warkentin, Thomas Malone, August NapierStemming from Gestalt foundations, change and growth occurs through an existential encounter with a therapist who is intentionally “real” and authentic with clients without pretence, often in a playful and sometimes absurd way as a means to foster flexibility in the family and promote individuation.Battling, constructive anxiety, redefining symptoms, affective confrontation, co-therapy, humour
Family mode deactivation therapy (FMDT)Jack A. ApscheTarget population adolescents with conduct and behavioural problems. Based on schema theory. Integrate mindfulness to focus family on the present. Validate core beliefs based on past experiences. Offer viable alternative responses. Treatment is based on case conceptualisation process; validate and clarify core beliefs, fears, triggers, and behaviours. Redirect behaviour by anticipating triggers and realigning beliefs and fears.Cognitive behavioural therapy, mindfulness, acceptance and commitment therapy, dialectical behaviour therapy, defusion, validate-clarify-redirect
Family-of-origin therapyJames FramoHe developed an object relations approach to intergenerational and family-of-origin therapy.Working with several generations of the family, family-of-origin approach with families in therapy and with trainees
Feminist family therapySandra Bem Marianne WaltersComplications from social and political disparity between genders are identified as underlying causes of conflict within a family system. Therapists are encouraged to be aware of these influences in order to avoid perpetuating hidden oppression, biases and cultural stereotypes and to model an egalitarian perspective of healthy family relationships.Demystifying, modelling, equality, personal accountability
Milan systemic family therapyLuigi Boscolo, Gianfranco Cecchin, Mara Selvini Palazzoli, Giuliana PrataA practical attempt by the “Milan Group” to establish therapeutic techniques based on Gregory Bateson’s cybernetics that disrupts unseen systemic patterns of control and games between family members by challenging erroneous family beliefs and reworking the family’s linguistic assumptions.Hypothesizing, circular questioning, neutrality, counter-paradox
MRI brief therapyGregory Bateson, Milton Erickson, Heinz von FoersterEstablished by the Mental Research Institute (MRI) as a synthesis of ideas from multiple theorists in order to interrupt misguided attempts by families to create first and second order change by persisting with “more of the same”, mixed signals from unclear metacommunication and paradoxical double-bind messages.Reframing, prescribing the symptom, relabelling, restraining (going slow), Bellac Ploy
Narrative therapyMichael White, David EpstonPeople use stories to make sense of their experience and to establish their identity as a social and political constructs based on local knowledge. Narrative therapists avoid marginalising their clients by positioning themselves as a co-editor of their reality with the idea that “the person is not the problem, but the problem is the problem.”Deconstruction, externalising problems, mapping, asking permission
Object relations therapyHazan & Shaver, David Scharff & Jill Scharff, James FramoIndividuals choose relationships that attempt to heal insecure attachments from childhood. Negative patterns established by their parents (object) are projected onto their partners.Detriangulation, co-therapy, psychoanalysis, holding environment
Psychoanalytic family therapyNathan AckermanBy applying the strategies of Freudian psychoanalysis to the family system therapists can gain insight into the interlocking psychopathologies of the family members and seek to improve complementarity.Psychoanalysis, authenticity, joining, confrontation
Solution focused therapyKim Insoo Berg, Steve de Shazer, William O’Hanlon, Michelle Weiner-Davis, Paul WatzlawickThe inevitable onset of constant change leads to negative interpretations of the past and language that shapes the meaning of an individual’s situation, diminishing their hope and causing them to overlook their own strengths and resources.Future focus, beginner’s mind, miracle question, goal setting, scaling
Strategic therapyJay Haley, Cloe MadanesSymptoms of dysfunction are purposeful in maintaining homeostasis in the family hierarchy as it transitions through various stages in the family life cycle.Directives, paradoxical injunctions, positioning, metaphoric tasks, restraining (going slow)
Structural family therapySalvador Minuchin, Harry Aponte, Charles Fishman, Braulio MontalvoFamily problems arise from maladaptive boundaries and subsystems that are created within the overall family system of rules and rituals that governs their interactions.Joining, family mapping, hypothesizing, re-enactments, reframing, unbalancing

Evidence Base

Family therapy has an evolving evidence base. A summary of current evidence is available via the UK’s Association of Family Therapy. Evaluation and outcome studies can also be found on the Family Therapy and Systemic Research Centre website. The website also includes quantitative and qualitative research studies of many aspects of family therapy.

According to a 2004 French government study conducted by French Institute of Health and Medical Research, family and couples therapy was the second most effective therapy after Cognitive behavioural therapy. The study used meta-analysis of over a hundred secondary studies to find some level of effectiveness that was either “proven” or “presumed” to exist. Of the treatments studied, family therapy was presumed or proven effective at treating schizophrenia, bipolar disorder, anorexia and alcohol dependency.

Concerns and Criticism

In a 1999 address to the Coalition of Marriage, Family and Couples Education conference in Washington, D.C., University of Minnesota Professor William Doherty said:

“I take no joy in being a whistle blower, but it’s time. I am a committed marriage and family therapist, having practiced this form of therapy since 1977. I train marriage and family therapists. I believe that marriage therapy can be very helpful in the hands of therapists who are committed to the profession and the practice. But there are a lot of problems out there with the practice of therapy – a lot of problems.”

Doherty suggested questions prospective clients should ask a therapist before beginning treatment:

  1. “Can you describe your background and training in marital therapy?”
  2. “What is your attitude toward salvaging a troubled marriage versus helping couples break up?”
  3. “What is your approach when one partner is seriously considering ending the marriage and the other wants to save it?”
  4. “What percentage of your practice is marital therapy?”
  5. “Of the couples you treat, what percentage would you say work out enough of their problems to stay married with a reasonable amount of satisfaction with the relationship.” “What percentage break up while they are seeing you?” “What percentage do not improve?” “What do you think makes the differences in these results?”

Licensing and Degrees

Family therapy practitioners come from a range of professional backgrounds, and some are specifically qualified or licensed/registered in family therapy (licensing is not required in some jurisdictions and requirements vary from place to place). In the United Kingdom, family therapists will have a prior relevant professional training in one of the helping professions usually psychologists, psychotherapists, or counsellors who have done further training in family therapy, either a diploma or an M.Sc. In the United States there is a specific degree and license as a marriage and family therapist; however, psychologists, nurses, psychotherapists, social workers, or counsellors, and other licensed mental health professionals may practice family therapy. In the UK, family therapists who have completed a four-year qualifying programme of study (MSc) are eligible to register with the professional body the Association of Family Therapy (AFT), and with the UK Council for Psychotherapy (UKCP).

A master’s degree is required to work as a Marriage and Family Therapist (MFT) in some American states. Most commonly, MFTs will first earn a M.S. or M.A. degree in marriage and family therapy, counselling, psychology, family studies, or social work. After graduation, prospective MFTs work as interns under the supervision of a licensed professional and are referred to as an MFTi.

Prior to 1999 in California, counsellors who specialised in this area were called Marriage, Family and Child Counsellors. Today, they are known as Marriage and Family Therapists (MFT), and work variously in private practice, in clinical settings such as hospitals, institutions, or counselling organisations.

Marriage and family therapists in the United States and Canada often seek degrees from accredited Masters or Doctoral programmes recognised by the Commission on Accreditation for Marriage and Family Therapy Education (COAMFTE), a division of the American Association of Marriage and Family Therapy.

Requirements vary, but in most states about 3,000 hours of supervised work as an intern are needed to sit for a licensing exam. MFTs must be licensed by the state to practice. Only after completing their education and internship and passing the state licensing exam can a person call themselves a Marital and Family Therapist and work unsupervised.

License restrictions can vary considerably from state to state. Contact information about licensing boards in the United States are provided by the Association of Marital and Family Regulatory Boards.

There have been concerns raised within the profession about the fact that specialist training in couples therapy – as distinct from family therapy in general – is not required to gain a license as an MFT or membership of the main professional body, the AAMFT.

Values and Ethics

Since issues of interpersonal conflict, power, control, values, and ethics are often more pronounced in relationship therapy than in individual therapy, there has been debate within the profession about the different values that are implicit in the various theoretical models of therapy and the role of the therapist’s own values in the therapeutic process, and how prospective clients should best go about finding a therapist whose values and objectives are most consistent with their own. An early paper on ethics in family therapy written by Vincenzo Di Nicola in consultation with a bioethicist asked basic questions about whether strategic interventions “mean what they say” and if it is ethical to invent opinions offered to families about the treatment process, such as statements saying that half of the treatment team believes one thing and half believes another. Specific issues that have emerged have included an increasing questioning of the longstanding notion of therapeutic neutrality, a concern with questions of justice and self-determination, connectedness and independence, “functioning” versus “authenticity”, and questions about the degree of the therapist’s “pro-marriage/family” versus “pro-individual” commitment.

The American Association for Marriage and Family Therapy requires members to adhere to a “Code of Ethics”, including a commitment to “continue therapeutic relationships only so long as it is reasonably clear that clients are benefiting from the relationship.”

Founders and Key Influences

Some key developers of family therapy are:

  • Alfred Adler (individual psychology).
  • Nathan Ackerman (psychoanalytic).
  • Tom Andersen (reflecting practices and dialogues about dialogues).
  • Harlene Anderson (postmodern collaborative therapy and Collaborative Language Systems).
  • Maurizio Andolfi (interactional, integrative, multigenerational, and relational family therapy).
  • Harry J Aponte (Person-of-the-Therapist).
  • Jack A. Apsche (family mode deactivation therapy, FMDT).
  • Gregory Bateson (1904–1980) (cybernetics, systems theory).
  • Ivan Boszormenyi-Nagy (contextual therapy, intergenerational, relational ethics).
  • Murray Bowen (systems theory, intergenerational).
  • Steve de Shazer (solution focused therapy).
  • Vincenzo Di Nicola (cultural family therapy).
  • Milton H. Erickson (hypnotherapy, strategic therapy, brief therapy).
  • Richard Fisch (brief therapy, strategic therapy).
  • James Framo (object relations theory, intergenerational, family-of-origin therapy).
  • Edwin Friedman (family process in religious congregations).
  • Harry Goolishian (postmodern collaborative therapy and collaborative language systems).
  • John Gottman (marriage).
  • Robert-Jay Green (LGBT, cross-cultural issues).
  • Douglas Haldane (Attachment-based couple therapist).
  • Jay Haley (strategic therapy, communications).
  • Lynn Hoffman (strategic, post-systems, collaborative).
  • Don D. Jackson (systems theory).
  • Sue Johnson (emotionally focused therapy, attachment theory).
  • Walter Kempler (Gestalt psychology).
  • Cloe Madanes (strategic therapy).
  • Salvador Minuchin (structural family therapy).
  • Braulio Montalvo (structural family therapy).
  • Virginia Satir (communications, experiential, conjoint and co-therapy).
  • Mara Selvini Palazzoli (Milan family systems therapy).
  • Karl Tomm (IPscope model and interventive interviewing, Bringforthism).
  • Robin Skynner (group analysis).
  • Paul Watzlawick (brief therapy, systems theory).
  • John Weakland (brief therapy, strategic therapy, systems theory).
  • Carl Whitaker (family systems, experiential, co-therapy).
  • Michael White (narrative therapy).
  • Lyman Wynne (schizophrenia, pseudomutuality).

What is a Double Bind?

Published on by Andrew Marshall2 Comments

Introduction

A double bind is a dilemma in communication in which an individual (or group) receives two or more conflicting messages, with one negating the other. In some circumstances (particularly families and relationships) this might be emotionally distressing. This creates a situation in which a successful response to one message results in a failed response to the other (and vice versa), so that the person will automatically be wrong regardless of response. The double bind occurs when the person cannot confront the inherent dilemma, and therefore can neither resolve it nor opt out of the situation.

Double bind theory was first described by Gregory Bateson and his colleagues in the 1950s.

Double binds are often utilised as a form of control without open coercion – the use of confusion makes them difficult both to respond to and to resist.

A double bind generally includes different levels of abstraction in the order of messages and these messages can either be stated explicitly or implicitly within the context of the situation, or they can be conveyed by tone of voice or body language. Further complications arise when frequent double binds are part of an ongoing relationship to which the person or group is committed.

Refer to Family Therapy and the Bateson Project (1953-1963).

Explanation

The double bind is often misunderstood to be a simple contradictory situation, where the subject is trapped by two conflicting demands. While it is true that the core of the double bind is two conflicting demands, the difference lies in how they are imposed upon the subject, what the subject’s understanding of the situation is, and who (or what) imposes these demands upon the subject. Unlike the usual no-win situation, the subject has difficulty in defining the exact nature of the paradoxical situation in which they are caught. The contradiction may be unexpressed in its immediate context and therefore invisible to external observers, only becoming evident when a prior communication is considered. Typically, a demand is imposed upon the subject by someone whom they respect (such as a parent, teacher, or doctor) but the demand itself is inherently impossible to fulfil because some broader context forbids it. For example, this situation arises when a person in a position of authority imposes two contradictory conditions but there exists an unspoken rule that one must never question authority.

Gregory Bateson and his colleagues defined the double bind as follows:

  1. The situation involves two or more people, one of whom (for the purpose of the definition), is designated as the “subject”. The others are people who are considered the subject’s superiors: figures of authority (such as parents), whom the subject respects.
  2. Repeated experience: the double bind is a recurrent theme in the experience of the subject, and as such, cannot be resolved as a single traumatic experience.
  3. A ‘primary injunction’ is imposed on the subject by the others generally in one of two forms:
    • (a) “Do X, or I will punish you”; or
    • (b) “Do not do X, or I will punish you.”
    • The punishment may include the withdrawing of love, the expression of hate and anger, or abandonment resulting from the authority figure’s expression of helplessness.
  4. A ‘secondary injunction’ is imposed on the subject, conflicting with the first at a higher and more abstract level. For example: “You must do X, but only do it because you want to.” It is unnecessary for this injunction to be expressed verbally.
  5. If necessary, a ‘tertiary injunction’ is imposed on the subject to prevent them from escaping the dilemma.
    • See phrase examples below for clarification.
  6. Finally, Bateson states that the complete list of the previous requirements may be unnecessary, in the event that the subject is already viewing their world in double bind patterns. Bateson goes on to give the general characteristics of such a relationship:
    • When the subject is involved in an intense relationship; that is, a relationship in which he feels it is vitally important that he discriminate accurately what sort of message is being communicated so that he may respond appropriately;
    • And, the subject is caught in a situation in which the other person in the relationship is expressing two orders of message and one of these denies the other;
    • And, the subject is unable to comment on the messages being expressed to correct his discrimination of what order of message to respond to: i.e., he cannot make a metacommunicative statement.

Thus, the essence of a double bind is two conflicting demands, each on a different logical level, neither of which can be ignored or escaped. This leaves the subject torn both ways, so that whichever demand they try to meet, the other demand cannot be met. “I must do it, but I can’t do it” is a typical description of the double-bind experience.

For a double bind to be effective, the subject must be unable to confront or resolve the conflict between the demand placed by the primary injunction and that of the secondary injunction. In this sense, the double bind differentiates itself from a simple contradiction to a more inexpressible internal conflict, where the subject really wants to meet the demands of the primary injunction, but fails each time through an inability to address the situation’s incompatibility with the demands of the secondary injunction. Thus, subjects may express feelings of extreme anxiety in such a situation, as they attempt to fulfil the demands of the primary injunction albeit with obvious contradictions in their actions.

This was a problem in United States legal circles prior to the Fifth Amendment to the United States Constitution being applied to state action. A person could be subpoenaed to testify in a federal case and given Fifth Amendment immunity for testimony in that case. However, since the immunity did not apply to a state prosecution, the person could refuse to testify at the Federal level despite being given immunity, thus subjecting the person to imprisonment for contempt of court, or the person could testify, and the information they were forced to give in the Federal proceeding could then be used to convict the person in a state proceeding.

Brief History

The term double bind was first used by the anthropologist Gregory Bateson and his colleagues (including Don D. Jackson, Jay Haley and John H. Weakland) in the mid-1950s in their discussions on complexity of communication in relation to schizophrenia. Bateson made clear that such complexities are common in normal circumstances, especially in “play, humour, poetry, ritual and fiction” (see Logical Types below). Their findings indicated that the tangles in communication often diagnosed as schizophrenia are not necessarily the result of an organic brain dysfunction. Instead, they found that destructive double binds were a frequent pattern of communication among families of patients, and they proposed that growing up amidst perpetual double binds could lead to learned patterns of confusion in thinking and communication.

Complexity in Communication

Human communication is complex, and context is an essential part of it. Communication consists of the words said, tone of voice, and body language. It also includes how these relate to what has been said in the past; what is not said, but is implied; how these are modified by other nonverbal cues, such as the environment in which it is said, and so forth. For example, if someone says “I love you”, one takes into account who is saying it, their tone of voice and body language, and the context in which it is said. It may be a declaration of passion or a serene reaffirmation, insincere and/or manipulative, an implied demand for a response, a joke, its public or private context may affect its meaning, and so forth.

Conflicts in communication are common and often we ask “What do you mean?” or seek clarification in other ways. This is called meta-communication: communication about the communication. Sometimes, asking for clarification is impossible. Communication difficulties in ordinary life often occur when meta-communication and feedback systems are lacking or inadequate or there is not enough time for clarification.

Double binds can be extremely stressful and become destructive when one is trapped in a dilemma and punished for finding a way out. But making the effort to find the way out of the trap can lead to emotional growth.

Examples

The classic example given of a negative double bind is of a mother telling her child that she loves them, while at the same time turning away in disgust, or inflicting corporal punishment as discipline: the words are socially acceptable; the body language is in conflict with it. The child does not know how to respond to the conflict between the words and the body language and, because the child is dependent on the mother for basic needs, they are in a quandary. Small children have difficulty articulating contradictions verbally and can neither ignore them nor leave the relationship.

Another example is when one is commanded to “be spontaneous”. The very command contradicts spontaneity, but it only becomes a double bind when one can neither ignore the command nor comment on the contradiction. Often, the contradiction in communication is not apparent to bystanders unfamiliar with previous communications.

Phrase Examples

  • An example from Gerald M. Weinberg in a non-family situation…. “I suggest you find someone who you feel is more capable in this role”.
    • This requires the recipient to either confirm that the current incumbent in the role is sufficiently capable, or accept that they choose someone else based on their feelings – not an objective assessment of whether the incumbent is capable.
  • Mother telling her child: “You must love me”.
  • The primary injunction here is the command itself: “you must”; the secondary injunction is the unspoken reality that love is spontaneous, that for the child to love the mother genuinely, it can only be of their own accord.
  • Child-abuser to child: “You should have escaped from me earlier, now it’s too late—because now, nobody will believe that you didn’t want what I have done”, while at the same time blocking all of the child’s attempts to escape.
  • Child-abusers often start the double-bind relationship by “grooming” the child, giving little concessions, or gifts or privileges to them, thus the primary injunction is: “You should like what you are getting from me!”
  • When the child begins to go along (i.e. begins to like what they are receiving from the person), then the interaction goes to the next level and small victimisation occurs, with the secondary injunction being: “I am punishing you! (for whatever reason the child-abuser is coming up with, e.g. “because you were bad/naughty/messy”, or “because you deserve it”, or “because you made me do it”, etc.).
  • If child shows any resistance (or tries to escape) from the abuser, then the words: “You should have escaped from me earlier (…)” serve as the third level or tertiary injunction.
  • Then the loop starts to feed on itself, allowing for ever worse victimisation to occur.
  • Mother to son: “Leave your sister alone!”, while the son knows his sister will approach and antagonize him to get him into trouble.
  • The primary injunction is the command, which he will be punished for breaking.
    • The secondary injunction is the knowledge that his sister will get into conflict with him, but his mother will not know the difference and will default to punishing him.
    • He may be under the impression that if he argues with his mother, he may be punished.
    • One possibility for the son to escape this double bind is to realise that his sister only antagonises him to make him feel anxious (if indeed it is the reason behind his sister’s behaviour).
  • If he were not bothered about punishment, his sister might not bother him.
    • He could also leave the situation entirely, avoiding both the mother and the sister.
    • The sister can not claim to be bothered by a non-present brother, and the mother can not punish (or scapegoat) a non-present son.
    • Other solutions exist too, which are based on the creative application of logic and reasoning.
  • An apt reply would be: “Please tell sis the same”. If mother wants to ‘scapegoat’ him, her response will be negative.
    • The command has a negative undertone towards the son.

Positive Double Binds

Bateson also described positive double binds, both in relation to Zen Buddhism with its path of spiritual growth, and the use of therapeutic double binds by psychiatrists to confront their patients with the contradictions in their life in such a way that would help them heal. One of Bateson’s consultants, Milton H. Erickson (5 volumes, edited by Rossi) eloquently demonstrated the productive possibilities of double binds through his own life, showing the technique in a brighter light.

The Science

One of the causes of double binds is the loss of feedback systems. Gregory Bateson and Lawrence S. Bale describe double binds that have arisen in science that have caused decades-long delays of progress in science because the scientific community had defined something as outside of its scope (or as “not science”) – see Bateson in his Introduction to Steps to an Ecology of Mind (1972, 2000), pp.xv–xxvi; and Bale in his article, Gregory Bateson, Cybernetics and the Social/Behavioural Sciences (esp. pp.1-8) on the paradigm of classical science vs. that of systems theory/cybernetics. (See also Bateson’s description in his Forward of how the double bind hypothesis fell into place).

Work by Bateson

Schizophrenia

The Double Bind Theory was first articulated in relationship to schizophrenia, but Bateson and his colleagues hypothesized that schizophrenic thinking was not necessarily an inborn mental disorder but a learned confusion in thinking.

It is helpful to remember the context in which these ideas were developed. Bateson and his colleagues were working in the Veteran’s Administration Hospital (1949-1962) with World War II veterans. As soldiers they’d been able to function well in combat, but the effects of life-threatening stress had affected them. At that time, 18 years before Post-Traumatic Stress Disorder was officially recognised, the veterans had been saddled with the catch-all diagnosis of schizophrenia. Bateson did not challenge the diagnosis but he did maintain that the seeming nonsense the patients said at times did make sense within context, and he gives numerous examples in section III of Steps to an Ecology of Mind, “Pathology in Relationship”. For example, a patient misses an appointment, and when Bateson finds him later the patient says ‘the judge disapproves’; Bateson responds, “You need a defense lawyer”. Bateson also surmised that people habitually caught in double binds in childhood would have greater problems – that in the case of the schizophrenic, the double bind is presented continually and habitually within the family context from infancy on. By the time the child is old enough to have identified the double bind situation, it has already been internalised, and the child is unable to confront it. The solution then is to create an escape from the conflicting logical demands of the double bind, in the world of the delusional system.

One solution to a double bind is to place the problem in a larger context, a state Bateson identified as Learning III, a step up from Learning II (which requires only learned responses to reward/consequence situations). In Learning III, the double bind is contextualized and understood as an impossible no-win scenario so that ways around it can be found.

Bateson’s double bind theory was never followed up by research into whether family systems imposing systematic double binds might be a cause of schizophrenia. This complex theory has been only partly tested, and there are gaps in the current psychological and experimental evidence required to establish causation. The current understanding of schizophrenia emphasizes the robust scientific evidence for a genetic predisposition to the disorder, with psychosocial stressors, including dysfunctional family interaction patterns, as secondary causative factors in some instances.

Evolution

After many years of research into schizophrenia, Bateson continued to explore problems of communication and learning, first with dolphins, and then with the more abstract processes of evolution. Bateson emphasised that any communicative system characterized by different logical levels might be subject to double bind problems. Especially including the communication of characteristics from one generation to another (genetics and evolution).

“…evolution always followed the pathways of viability. As Lewis Carroll has pointed out, the theory [of natural selection] explains quite satisfactorily why there are no bread-and-butter-flies today.”

Bateson used the fictional Bread and Butter Fly (from Through the Looking Glass, and What Alice Found There) to illustrate the double bind in terms of natural selection. The gnat points out that the insect would be doomed if he found his food (which would dissolve his own head, since this insect’s head is made of sugar, and his only food is tea), and starve if he did not. Alice suggests that this must happen quite often, to which the gnat replies: “It always happens.”

The pressures that drive evolution therefore represent a genuine double bind. And there is truly no escape: “It always happens.” No species can escape natural selection, including our own.

Bateson suggested that all evolution is driven by the double bind, whenever circumstances change: If any environment becomes toxic to any species, that species will die out unless it transforms into another species, in which case, the species becomes extinct anyway.

Most significant here is Bateson’s exploration of what he later came to call ‘the pattern that connects’ – that problems of communication which span more than one level (e.g. the relationship between the individual and the family) should also be expected to be found spanning other pairs of levels in the hierarchy (e.g. the relationship between the genotype and the phenotype):

“We are very far, then, from being able to pose specific questions for the geneticist; but I believe that the wider implications of what I have been saying modify somewhat the philosophy of genetics. Our approach to the problems of schizophrenia by way of a theory of levels or logical types has disclosed first that the problems of adaptation and learning and their pathologies must be considered in terms of a hierarchic system in which stochastic change occurs at the boundary points between the segments of the hierarchy. We have considered three such regions of stochastic change—the level of genetic mutation, the level of learning, and the level of change in family organization. We have disclosed the possibility of a relationship of these levels which orthodox genetics would deny, and we have disclosed that at least in human societies the evolutionary system consists not merely in the selective survival of those persons who happen to select appropriate environments but also in the modification of family environment in a direction which might enhance the phenotypic and genotypic characteristics of the individual members.”

Girard’s Mimetic Double Bind

René Girard, in his literary theory of mimetic desire, proposes what he calls a “model-obstacle”, a role model who demonstrates an object of desire and yet, in possessing that object, becomes a rival who obstructs fulfilment of the desire. According to Girard, the “internal mediation” of this mimetic dynamic “operates along the same lines as what Gregory Bateson called the ‘double bind’.” Girard found in Sigmund Freud’s psychoanalytic theory, a precursor to mimetic desire. “The individual who ‘adjusts’ has managed to relegate the two contradictory injunctions of the double bind—to imitate and not to imitate—to two different domains of application. This is, he divides reality in such a way as to neutralize the double bind.” While critical of Freud’s doctrine of the unconscious mind, Girard sees the ancient Greek tragedy, Oedipus Rex, and key elements of Freud’s Oedipus complex, patricidal and incestuous desire, to serve as prototypes for his own analysis of the mimetic double bind.

Far from being restricted to a limited number of pathological cases, as American theoreticians suggest, the double bind – a contradictory double imperative, or rather a whole network of contradictory imperatives – is an extremely common phenomenon. In fact, it is so common that it might be said to form the basis of all human relationships.

Bateson is undoubtedly correct in believing that the effects of the double bind on the child are particularly devastating. All the grown-up voices around him, beginning with those of the father and mother (voices which, in our society at least, speak for the culture with the force of established authority) exclaim in a variety of accents, “Imitate us!” “Imitate me!” “I bear the secret of life, of true being!” The more attentive the child is to these seductive words, and the more earnestly he responds to the suggestions emanating from all sides, the more devastating will be the eventual conflicts. The child possesses no perspective that will allow him to see things as they are. He has no basis for reasoned judgements, no means of foreseeing the metamorphosis of his model into a rival. This model’s opposition reverberates in his mind like a terrible condemnation; he can only regard it as an act of excommunication. The future orientation of his desires – that is, the choice of his future models – will be significantly affected by the dichotomies of his childhood. In fact, these models will determine the shape of his personality.

If desire is allowed its own bent, its mimetic nature will almost always lead it into a double bind. The unchanneled mimetic impulse hurls itself blindly against the obstacle of a conflicting desire. It invites its own rebuffs and these rebuffs will in turn strengthen the mimetic inclination. We have, then, a self-perpetuating process, constantly increasing in simplicity and fervor. Whenever the disciple borrows from his model what he believes to be the “true” object, he tries to possess that truth by desiring precisely what this model desires. Whenever he sees himself closest to the supreme goal, he comes into violent conflict with a rival. By a mental shortcut that is both eminently logical and self-defeating, he convinces himself that the violence itself is the most distinctive attribute of this supreme goal! Ever afterward, violence will invariably awaken desire… (René Girard, Violence and the Sacred: “From Mimetic Desire to the Monstrous Double”, pp.156-157).

Neuro-Linguistic Programming

The field of Neuro-Linguistic Programming (NLP) also makes use of the expression “double bind”. Grinder and Bandler (both of whom had personal contact with Bateson and Erickson) asserted that a message could be constructed with multiple messages, whereby the recipient of the message is given the impression of choice – although both options have the same outcome at a higher level of intention. This is called a “double bind” in NLP terminology, and has applications in both sales and therapy. In therapy, the practitioner may seek to challenge destructive double binds that limit the client in some way and may also construct double binds in which both options have therapeutic consequences. In a sales context, the speaker may give the respondent the illusion of choice between two possibilities. For example, a salesperson might ask: “Would you like to pay cash or by credit card?”, with both outcomes presupposing that the person will make the purchase; whereas the third option (that of not buying) is intentionally excluded from the spoken choices.

Note that in the NLP context, the use of the phrase “double bind” does not carry the primary definition of two conflicting messages; it is about creating a false sense of choice which ultimately binds to the intended outcome. In the “cash or credit card?” example, this is not a “Bateson double bind” since there is no contradiction, although it still is an “NLP double bind”. Similarly if a salesman were selling a book about the evils of commerce, it could perhaps be a “Bateson double bind” if the buyer happened to believe that commerce was evil, yet felt compelled or obliged to buy the book.

What was the Bateson Project?

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Introduction

The Bateson Project (1953-1963) was the name given to a ground-breaking collaboration organised by Gregory Bateson which was responsible for some of the most important papers and innovations in communication and psychotherapy in the 1950s and early 1960s. Its other members were Donald deAvila Jackson, Jay Haley, John Weakland, and Bill Fry.

Background

Perhaps their most famous and influential publication was Towards a Theory of Schizophrenia (1956), which introduced the concept of the Double Bind, and helped found Family Therapy.

One of the project’s first locations was the Menlo Park VA Hospital, which was chosen because of Bateson’s previous work there as an ethnologist. The initial research, which was funded by a Rockefeller grant, focused on “strange communication” and nonsensical language among the patients of the institution who were suffering from schizophrenia. The group studied this within the context of double bind communication in family dynamics.

Refer to Double Bind and Family Therapy.

Can the MHS: A Serve as a Clinically Useful Screening Tool for GAD?

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Research Paper Title

A Brief Online and Offline (Paper-and-Pencil) Screening Tool for Generalized Anxiety Disorder: The Final Phase in the Development and Validation of the Mental Health Screening Tool for Anxiety Disorders (MHS: A).

Background

Generalised anxiety disorder (GAD) can cause significant socioeconomic burden and daily life dysfunction; hence, therapeutic intervention through early detection is important.

Methods

This study was the final stage of a 3-year anxiety screening tool development project that evaluated the psychometric properties and diagnostic screening utility of the Mental Health Screening Tool for Anxiety Disorders (MHS: A), which measures GAD.

Results

A total of 527 Koreans completed online and offline (i.e., paper-and pencil) versions of the MHS: A, Beck Anxiety Inventory (BAI), Generalised Anxiety Disorder-7 (GAD-7), and Penn State Worry Questionnaire (PSWQ). The participants had an average age of 38.6 years and included 340 (64.5%) females. Participants were also administered the Mini-International Neuropsychiatric Interview (MINI).

Internal consistency, convergent/criterion validity, item characteristics, and test information were assessed based on the item response theory (IRT), and a factor analysis and cut-off score analyses were conducted. The MHS: A had good internal consistency and good convergent validity with other anxiety scales.

The two versions (online/offline) of the MHS: A were nearly identical (r = 0.908). It had a one-factor structure and showed better diagnostic accuracy (online/offline: sensitivity = 0.98/0.90, specificity = 0.80/0.83) for GAD detection than the GAD-7 and BAI. The IRT analysis indicated that the MHS: A was most informative as a screening tool for GAD.

Conclusions

The MHS: A can serve as a clinically useful screening tool for GAD in Korea. Furthermore, it can be administered both online and offline and can be flexibly used as a brief mental health screener, especially with the current rise in telehealth.

Reference

Kim, S-H., Park, K., Yoon, S., Choi, Y., Lee, S-H. & Choi, K-H. (2021) A Brief Online and Offline (Paper-and-Pencil) Screening Tool for Generalized Anxiety Disorder: The Final Phase in the Development and Validation of the Mental Health Screening Tool for Anxiety Disorders (MHS: A). Frontiers in Psychology. doi: 10.3389/fpsyg.2021.639366. eCollection 2021.

On This Day … 04 April

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People (Deaths)

  • 2012 – A. Dean Byrd, American psychologist and academic (b. 1948).

A. Dean Byrd

Albert Dean Byrd (1948 to 4 April 2012) was a former president of the National Association for Research & Therapy of Homosexuality (NARTH), a research organisation that advocates sexual orientation change efforts (SOCE).

He was a psychologist who focused on SOCE, and wrote on the topic. Although raised by a Buddhist mother and a Baptist father, Byrd converted to The Church of Jesus Christ of Latter-day Saints (LDS Church) and was very active in the debate within the church on issues involving homosexuality.

Professional Life

Byrd was a well known supporter of conversion therapy, and authored more than 100 publications, including books, peer-reviewed scientific journals, law journals, book chapters, invited commentaries and opinion editorials, many of which addressed issues of human sexuality. In 2002, he presented a paper which describes a technique called gender-affirmative therapy. He stated: “The basic premise of gender-affirmative therapy is that social and emotional variables affect gender identity which, in turn, determines sexual orientation. The work of the therapist is to help people understand their gender development. Subsequently, such individuals are able to make choices that are consistent with their value system. The focus of therapy is to help clients fully develop their masculine or feminine identity”. He wrote several papers with Joseph Nicolosi. One of the largest was a survey of 882 people who were undergoing therapy, attending ex-gay groups or ex-gay conferences: 22.9% reported they had not undergone any changes, 42.7% reported some changes, and 34.3% reported much change in sexual orientation. As a group, they reported large reductions in homosexual thoughts and fantasies and improvements in their psychological, interpersonal, and spiritual well-being. He promoted his ideas on college campuses, in newspapers, and in several books. He was called as a professional witness to testify on behalf of Andrew McClintock, a Christian magistrate who was forced to resign due to his beliefs on homosexual parents. In 2007, he was asked to chair a symposium at the APA Convention in San Francisco.

Byrd received a Ph.D. in psychology from Brigham Young University (BYU), a post-doctoral degree in Child and Family Psychology from Virginia Commonwealth University and Medical College of Virginia, and a post-doctoral degree in Behavioral Medicine from Loyola University, Chicago. He also received both an M.P.H. from the University of Utah (U of U), School of Medicine, and an M.B.A. also from the U of U. He was a diplomate in forensic medicine.

Byrd served as the Director of Clinical Training for LDS Social Services, was a Clinical Professor at BYU, and was, at the time of his death, a Clinical Professor at the University of Utah, School of Medicine, with appointments in the Department of Family and Preventive Medicine and in Department of Psychiatry, with an adjunct clinical appointment in the Department of Family Studies, also at the University of Utah. As member of the faculty at the U of U, he lectured training medical students about disparities in health care in the population. He was also a member of the American Psychological Association, the Utah Psychological Association where he served on the governing board, with professional affiliations in the American Orthopsychiatric Association, where he was a fellow, the American Public Health Association, the American Board of Forensic Examiners and the Prescribing Psychologist Register, a training and credentialing organization for psychologists in psychopharmacology. He was also a former member of the Evergreen Board of Trustees. He was also the president of Thrasher Research Fund, a paediatric research granting institution. In 2007, he was elected as president of NARTH for 2008. Byrd had visiting professor appointments in Israel and Poland. He also had training in genetics, biochemistry and neurochemistry from the University of California at Berkeley.

Death

Byrd died of cancer on 04 April 2012.

On This Day … 03 April

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People (Births)

  • 1860 – Frederik van Eeden, Dutch psychiatrist and author (d. 1932).

Frederik van Eeden

Frederik Willem van Eeden (03 April 1860 to 16 June 1932) was a late 19th-century and early 20th-century Dutch writer and psychiatrist. He was a leading member of the Tachtigers and the Significs Group, and had top billing among the editors of De Nieuwe Gids (The New Guide) during its celebrated first few years of publication, starting in 1885.

Biography

Van Eeden was the son of Frederik Willem Van Eeden, director of the Royal Tropical Institute in Haarlem.

In 1880 he studied Medicine in Amsterdam, where he pursued a bohemian lifestyle and wrote poetry. Whilst living in the city, he coined the term lucid dream in the sense of mental clarity, a term that nowadays is a classic term in the Dream literature and study, meaning dreaming while knowing that one is dreaming. In his early writings, he was strongly influenced by Hindu ideas of selfhood, by Boehme’s mysticism, and by Fechner’s panpsychism.

He went on to become a prolific writer, producing many critically acclaimed novels, poetry, plays, and essays. He was widely admired in the Netherlands in his own time for his writings, as well as his status as the first internationally prominent Dutch psychiatrist.

Van Eeden’s psychiatrist practice included treating his fellow Tachtiger Willem Kloos as a patient starting in 1888. His treatment of Kloos was of limited benefit, as Kloos deteriorated into alcoholism and increasing symptoms of mental illness. Van Eeden also incorporated his psychiatric insights into his later writings, such as in a deeply psychological novel called “Van de koele meren des doods” (translated in English as “The Deeps of Deliverance”). Published in 1900, the novel intimately traced the struggle of a woman addicted to morphine as she deteriorated physically and mentally.

His best known written work, “De Kleine Johannes” (“Little Johannes”), which first appeared in the premiere issue of De Nieuwe Gids, was a fantastical adventure of an everyman who grows up to face the harsh realities of the world around him and the emptiness of hopes for a better afterlife, but ultimately finding meaning in serving the good of those around him. This ethic is memorialized in the line “Waar de mensheid is, en haar weedom, daar is mijn weg.” (“Where mankind is, and her woe, there is my path.”).

Van Eeden sought not only to write about, but also to practice, such an ethic. He established a commune named Walden (commune) [nl], taking inspiration from Thoreau’s book Walden, in Bussum, North Holland, where the residents tried to produce as much of their needs as they could themselves and to share everything in common, and where he took up a standard of living far below what he was used to. This reflected a trend toward socialism among the Tachtigers; another Tachtiger, Herman Gorter, was a founding member of the world’s first Communist political party, the Dutch Social-Democratic Party, in 1909.

Van Eeden visited the US. He had contacts with William James and other psychologists. He met Freud in Vienna, whom he practically introduced in the Netherlands. He corresponded with Hermann Hesse, Charles Lloyd Tuckey (medical hypnotist), Harold Williams (linguist) and was a friend of Peter Kropotkin, the Russian anarchist living in London (UK).

Van Eeden also had a keen interest in Indian philosophy. He translated many of Tagore’s works, including Gitanjali and short stories.

In late years of his life, Van Eeden became a Roman Catholic.

What is an Eating Disorder?

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Introduction

An eating disorder is a mental disorder defined by abnormal eating habits that negatively affect a person’s physical and/or mental health.

Types of eating disorders include binge eating disorder, where people eat a large amount in a short period of time; anorexia nervosa, where people have an intense fear of gaining weight and restrict food or over-exercise to manage this fear; bulimia nervosa, where people eat a lot and then try to rid themselves of the food; pica, where people eat non-food items; rumination syndrome, where people regurgitate food; avoidant/restrictive food intake disorder (ARFID), where people have a reduced or selective food intake due to some psychological reasons (see below); and a group of other specified feeding or eating disorders. Anxiety disorders, depression and substance abuse are common among people with eating disorders. These disorders do not include obesity.

The causes of eating disorders are not clear, although both biological and environmental factors appear to play a role. Eating disorders affect about 12% of dancers. Cultural idealisation of thinness is believed to contribute to some eating disorders. Individuals who have experienced sexual abuse are also more likely to develop eating disorders. Some disorders such as pica and rumination disorder occur more often in people with intellectual disabilities. Only one eating disorder can be diagnosed at a given time.

Treatment can be effective for many eating disorders. Treatment varies by disorder and may involve counselling, dietary advice, reducing excessive exercise and the reduction of efforts to eliminate food. Medications may be used to help with some of the associated symptoms. Hospitalisation may be needed in more serious cases. About 70% of people with anorexia and 50% of people with bulimia recover within five years. Recovery from binge eating disorder is less clear and estimated at 20% to 60%. Both anorexia and bulimia increase the risk of death.

In the developed world, anorexia affects about 0.4% and bulimia affects about 1.3% of young women in a given year. Binge eating disorder affects about 1.6% of women and 0.8% of men in a given year. Among women about 4% have anorexia, 2% have bulimia, and 2% have binge eating disorder at some time in their life. Rates of eating disorders appear to be lower in less developed countries. Anorexia and bulimia occur nearly ten times more often in females than males. Eating disorders typically begin in late childhood or early adulthood. Rates of other eating disorders are not clear.

Classification

ICD and DSM Diagnoses

These eating disorders are specified as mental disorders in standard medical manuals, including the ICD-10 and the DSM-5.

  • Anorexia Nervosa (AN):
    • This is the restriction of energy intake relative to requirements, leading to a significantly low body weight in the context of age, sex, developmental trajectory, and physical health.
    • It is accompanied by an intense fear of gaining weight or becoming fat, as well as a disturbance in the way one experiences and appraises their body weight or shape.
    • There are two subtypes of AN:
      • The restricting type; and
      • The binge-eating/purging type.
    • The restricting type describes presentations in which weight loss is attained through dieting, fasting, and/or excessive exercise, with an absence of binge/purge behaviours.
    • The binge-eating/purging type describes presentations in which the individual suffering has engaged in recurrent episodes of binge-eating and purging behaviour, such as self-induced vomiting, misuse of laxatives, and diuretics.
    • Severity of AN is determined by BMI, with BMIs below 15 noted as the most extreme cases of the disorder.
    • Pubertal and post-pubertal females with anorexia often experience amenorrhea, or the loss of menstrual periods, due to the extreme weight loss these individuals face.
    • Although amenorrhea was a required criterion for a diagnosis of anorexia in the DSM-IV, it was dropped in the DSM-5 due to its exclusive nature, as male, post-menopause women, or individuals who do not menstruate for other reasons would fail to meet this criterion.
    • Females with bulimia may also experience amenorrhea, although the cause is not clear.
  • Bulimia Nervosa (BN):
    • This is characterised by recurrent binge eating followed by compensatory behaviours such as purging (self-induced vomiting, eating to the point of vomiting, excessive use of laxatives/diuretics, or excessive exercise).
    • Fasting may also be used as a method of purging following a binge.
    • However, unlike anorexia nervosa, body weight is maintained at or above a minimally normal level.
    • Severity of BN is determined by the number of episodes of inappropriate compensatory behaviours per week.
  • Binge Eating Disorder (BED):
    • This is characterised by recurrent episodes of binge eating without use of inappropriate compensatory behaviours that are present in BN and AN binge-eating/purging subtype.
    • Binge eating episodes are associated with eating much more rapidly than normal, eating until feeling uncomfortably full, eating large amounts of food when not feeling physically hungry, eating alone because of feeling embarrassed by how much one is eating, and/or feeling disgusted with oneself, depressed or very guilty after eating.
    • For a BED diagnosis to be given, marked distress regarding binge eating must be present, and the binge eating must occur an average of once a week for 3 months.
    • Severity of BED is determined by the number of binge eating episodes per week.
  • Pica:
    • This is the persistent eating of non-nutritive, non-food substances in a way that is not developmentally appropriate or culturally supported.
    • Although substances consumed vary with age and availability, paper, soap, hair, chalk, paint, and clay are among the most commonly consumed in those with a pica diagnosis.
    • There are multiple causes for the onset of pica, including iron-deficiency anaemia, malnutrition, and pregnancy, and pica often occurs in tandem with other mental health disorders associated with impaired function, such as intellectual disability, autism spectrum disorder, and schizophrenia.
    • In order for a diagnosis of pica to be warranted, behaviours must last for at least one month.
  • Rumination Disorder:
    • This encompasses the repeated regurgitation of food, which may be re-chewed, re-swallowed, or spit out.
    • For this diagnosis to be warranted, behaviours must persist for at least one month, and regurgitation of food cannot be attributed to another medical condition.
    • Additionally, rumination disorder is distinct from AN, BN, BED, and ARFID, and thus cannot occur during the course of one of these illnesses.
  • Avoidant/Restrictive Food Intake Disorder (ARFID):
    • This is a feeding or eating disturbance, such as a lack of interest in eating food, avoidance based on sensory characteristics of food, or concern about aversive consequences of eating, that prevents one from meeting nutritional energy needs.
    • It is frequently associated with weight loss, nutritional deficiency, or failure to meet growth trajectories.
    • Notably, ARFID is distinguishable from AN and BN in that there is no evidence of a disturbance in the way in which one’s body weight or shape is experienced.
    • The disorder is not better explained by lack of available food, cultural practices, a concurrent medical condition, or another mental disorder.
  • Other Specified Feeding or Eating Disorder (OSFED):
    • This is an eating or feeding disorder that does not meet full DSM-5 criteria for AN, BN, or BED.
    • Examples of otherwise-specified eating disorders include individuals with atypical anorexia nervosa, who meet all criteria for AN except being underweight despite substantial weight loss; atypical bulimia nervosa, who meet all criteria for BN except that bulimic behaviours are less frequent or have not been ongoing for long enough; purging disorder; and night eating syndrome.
  • Unspecified Feeding or Eating Disorder (USFED):
    • This describes feeding or eating disturbances that cause marked distress and impairment in important areas of functioning but that do not meet the full criteria for any of the other diagnoses.
    • The specific reason the presentation does not meet criteria for a specified disorder is not given.
    • For example, an USFED diagnosis may be given when there is insufficient information to make a more specific diagnosis, such as in an emergency room setting.

Other

  • Compulsive Overeating:
    • This may include habitual “grazing” of food or episodes of binge eating without feelings of guilt.
  • Diabulimia:
    • This is characterised by the deliberate manipulation of insulin levels by diabetics in an effort to control their weight.
  • Drunkorexia:
    • This is commonly characterised by purposely restricting food intake in order to reserve food calories for alcoholic calories, exercising excessively in order to burn calories from drinking, and over-drinking alcohol in order to purge previously consumed food.
  • Food Maintenance:
    • This is characterised by a set of aberrant eating behaviours of children in foster care.
  • Night Eating Syndrome:
    • This is characterised by nocturnal hyperphagia (consumption of 25% or more of the total daily calories after the evening meal) with nocturnal ingestions, insomnia, loss of morning appetite and depression.
  • Nocturnal Sleep-Related Eating Disorder:
    • This is a parasomnia characterised by eating, habitually out-of-control, while in a state of NREM sleep, with no memory of this the next morning.
  • Gourmand Syndrome:
    • This is a rare condition occurring after damage to the frontal lobe.
    • Individuals develop an obsessive focus on fine foods.
  • Orthorexia Nervosa:
    • This is a term used to describe an obsession with a “pure” diet, in which a person develops an obsession with avoiding unhealthy foods to the point where it interferes with the person’s life.
  • Klüver-Bucy Syndrome:
    • This is caused by bilateral lesions of the medial temporal lobe and includes compulsive eating, hypersexuality, hyperorality, visual agnosia, and docility.
  • Prader-Willi Syndrome:
    • This is a genetic disorder associated with insatiable appetite and morbid obesity.
  • Pregorexia:
    • This is characterised by extreme dieting and over-exercising in order to control pregnancy weight gain. Prenatal undernutrition is associated with low birth weight, coronary heart disease, type 2 diabetes, stroke, hypertension, cardiovascular disease risk, and depression.
  • Muscle Dysmorphia:
    • This is characterised by appearance preoccupation that one’s own body is too small, too skinny, insufficiently muscular, or insufficiently lean.
    • Muscle dysmorphia affects mostly males.
  • Purging Disorder:
    • This is recurrent purging behaviour to influence weight or shape in the absence of binge eating.
    • It is more properly a disorder of elimination rather than eating disorder.

Symptoms and Long-Term Effects

Symptoms and complications vary according to the nature and severity of the eating disorder.

Associated physical symptoms of eating disorders include weakness, fatigue, sensitivity to cold, reduced beard growth in men, reduction in waking erections, reduced libido, weight loss and growth failure. Frequent vomiting, which may cause acid reflux or entry of acidic gastric material into the laryngoesophageal tract, can lead to unexplained hoarseness. As such, individuals who induce vomiting as part of their eating disorder, such as those with anorexia nervosa, binge eating-purging type or those with purging-type bulimia nervosa, are at risk for acid reflux.

Possible Complications

  • Acne.
  • Xerosis.
  • Amenorrhoea.
  • Tooth loss.
  • Cavities.
  • Constipation.
  • Diarrhoea.
  • Water retention and/or oedema.
  • Lanugo.
  • Telogen effluvium.
  • Cardiac arrest.
  • Hypokalaemia.
  • Death/suicide.
  • Osteoporosis.
  • Electrolyte imbalance.
  • Hyponatraemia.
  • Brain atrophy.
  • Pellagra.
  • Scurvy.
  • Kidney failure.

Frequent vomiting, which may cause acid reflux or entry of acidic gastric material into the laryngoesophageal tract, can lead to unexplained hoarseness. As such, individuals who induce vomiting as part of their eating disorder, such as those with anorexia nervosa, binge eating-purging type or those with purging-type bulimia nervosa, are at risk for acid reflux.

Polycystic ovary syndrome (PCOS) is the most common endocrine disorder to affect women. Though often associated with obesity it can occur in normal weight individuals. PCOS has been associated with binge eating and bulimic behaviour.

Other possible manifestations are dry lips, burning tongue, parotid gland swelling, and temporomandibular disorders.

Pro-Ana Subculture

Pro-ana refers to the promotion of behaviours related to the eating disorder anorexia nervosa. Several websites promote eating disorders, and can provide a means for individuals to communicate in order to maintain eating disorders. Members of these websites typically feel that their eating disorder is the only aspect of a chaotic life that they can control. These websites are often interactive and have discussion boards where individuals can share strategies, ideas, and experiences, such as diet and exercise plans that achieve extremely low weights. A study comparing the personal web-blogs that were pro-eating disorder with those focused on recovery found that the pro-eating disorder blogs contained language reflecting lower cognitive processing, used a more closed-minded writing style, contained less emotional expression and fewer social references, and focused more on eating-related contents than did the recovery blogs.

Psychopathology

The psychopathology of eating disorders centres around body image disturbance, such as concerns with weight and shape; self-worth being too dependent on weight and shape; fear of gaining weight even when underweight; denial of how severe the symptoms are and a distortion in the way the body is experienced.

The main psychopathological features of anorexia were outlined in 1982 as problems in body perception, emotion processing and interpersonal relationships. Women with eating disorders have greater body dissatisfaction. This impairment of body perception involves vision, proprioception, and tactile perception. There is an alteration in integration of signals in which body parts are experienced as dissociated from the body as a whole. Bruch theorised that difficult early relationships were related to the cause of anorexia and how primary caregivers can contribute to the onset of the illness.

A prominent feature of bulimia is dissatisfaction with body shape. However, dissatisfaction with body shape is not of diagnostic significance as it is sometimes present in individuals with no eating disorder. This highly labile feature can fluctuate depending on changes in shape and weight, the degree of control over eating and mood. In contrast, a necessary diagnostic feature for anorexia nervosa and bulimia nervosa is having overvalued ideas about shape and weight are relatively stable and closely related to the patients’ low self-esteem.

Causes

Many people with eating disorders also have body dysmorphic disorder, altering the way a person sees oneself. Studies have found that a high proportion of individuals diagnosed with body dysmorphic disorder also had some type of eating disorder, with 15% of individuals having either anorexia nervosa or bulimia nervosa. This link between body dysmorphic disorder and anorexia stems from the fact that both BDD and anorexia nervosa are characterised by a preoccupation with physical appearance and a distortion of body image. There are also many other possibilities such as environmental, social and interpersonal issues that could promote and sustain these illnesses. Also, the media are oftentimes blamed for the rise in the incidence of eating disorders due to the fact that media images of idealised slim physical shape of people such as models and celebrities motivate or even force people to attempt to achieve slimness themselves. The media are accused of distorting reality, in the sense that people portrayed in the media are either naturally thin and thus unrepresentative of normality or unnaturally thin by forcing their bodies to look like the ideal image by putting excessive pressure on themselves to look a certain way. While past findings have described eating disorders as primarily psychological, environmental, and sociocultural, further studies have uncovered evidence that there is a genetic component.

Genetics

Numerous studies show a genetic predisposition toward eating disorders. Twin studies have found a slight instances of genetic variance when considering the different criterion of both anorexia nervosa and bulimia nervosa as endophenotypes contributing to the disorders as a whole. A genetic link has been found on chromosome 1 in multiple family members of an individual with anorexia nervosa. An individual who is a first degree relative of someone who has had or currently has an eating disorder is seven to twelve times more likely to have an eating disorder themselves. Twin studies also show that at least a portion of the vulnerability to develop eating disorders can be inherited, and there is evidence to show that there is a genetic locus that shows susceptibility for developing anorexia nervosa. About 50% of eating disorder cases are attributable to genetics. Other cases are due to external reasons or developmental problems. There are also other neurobiological factors at play tied to emotional reactivity and impulsivity that could lead to binging and purging behaviours.

Epigenetics mechanisms are means by which environmental effects alter gene expression via methods such as DNA methylation; these are independent of and do not alter the underlying DNA sequence. They are heritable, but also may occur throughout the lifespan, and are potentially reversible. Dysregulation of dopaminergic neurotransmission due to epigenetic mechanisms has been implicated in various eating disorders. Other candidate genes for epigenetic studies in eating disorders include leptin, pro-opiomelanocortin (POMC) and brain-derived neurotrophic factor (BDNF).

Psychological

Eating disorders were classified as Axis I disorders in DSM-IV. There are various other psychological issues that may factor into eating disorders, some fulfil the criteria for a separate Axis I diagnosis or a personality disorder which is coded Axis II and thus are considered comorbid to the diagnosed eating disorder. Axis II disorders are subtyped into 3 “clusters”: A, B and C. The causality between personality disorders and eating disorders has yet to be fully established. Some people have a previous disorder which may increase their vulnerability to developing an eating disorder. Some develop them afterwards. The severity and type of eating disorder symptoms have been shown to affect comorbidity. The DSM-IV should not be used by laypersons to diagnose themselves even when used by professionals as there has been considerable controversy over the diagnostic criteria used for various diagnoses, including eating disorders. There has been controversy over various editions of the DSM including the latest edition (then DSM-V).

Comorbid Disorders

Cognitive Attentional Bias

Attentional bias may have an effect on eating disorders. Attentional bias is the preferential attention toward certain types of information in the environment while simultaneously ignoring others. Individuals with eating disorders can be thought to have schemas, knowledge structures, which are dysfunctional as they may bias judgement, thought, behaviour in a manner that is self-destructive or maladaptive. They may have developed a disordered schema which focuses on body size and eating. Thus, this information is given the highest level of importance and overvalued among other cognitive structures. Researchers have found that people who have eating disorders tend to pay more attention to stimuli related to food. For people struggling to recover from an eating disorder or addiction, this tendency to pay attention to certain signals while discounting others can make recovery that much more difficult.

Studies have utilised the Stroop task to assess the probable effect of attentional bias on eating disorders. This may involve separating food and eating words from body shape and weight words. Such studies have found that anorexic subjects were slower to colour name food related words than control subjects. Other studies have noted that individuals with eating disorders have significant attentional biases associated with eating and weight stimuli.

Personality Traits

There are various childhood personality traits associated with the development of eating disorders. During adolescence these traits may become intensified due to a variety of physiological and cultural influences such as the hormonal changes associated with puberty, stress related to the approaching demands of maturity and socio-cultural influences and perceived expectations, especially in areas that concern body image. Eating disorders have been associated with a fragile sense of self and with disordered mentalisation. Many personality traits have a genetic component and are highly heritable. Maladaptive levels of certain traits may be acquired as a result of anoxic or traumatic brain injury, neurodegenerative diseases such as Parkinson’s disease, neurotoxicity such as lead exposure, bacterial infection such as Lyme disease or parasitic infection such as Toxoplasma gondii as well as hormonal influences. While studies are still continuing via the use of various imaging techniques such as fMRI; these traits have been shown to originate in various regions of the brain such as the amygdala and the prefrontal cortex. Disorders in the prefrontal cortex and the executive functioning system have been shown to affect eating behaviour.

Celiac Disease

People with gastrointestinal disorders may be more risk of developing disordered eating practices than the general population, principally restrictive eating disturbances. An association of anorexia nervosa with celiac disease has been found. The role that gastrointestinal symptoms play in the development of eating disorders seems rather complex. Some authors report that unresolved symptoms prior to gastrointestinal disease diagnosis may create a food aversion in these persons, causing alterations to their eating patterns. Other authors report that greater symptoms throughout their diagnosis led to greater risk. It has been documented that some people with celiac disease, irritable bowel syndrome or inflammatory bowel disease who are not conscious about the importance of strictly following their diet, choose to consume their trigger foods to promote weight loss. On the other hand, individuals with good dietary management may develop anxiety, food aversion and eating disorders because of concerns around cross contamination of their foods. Some authors suggest that medical professionals should evaluate the presence of an unrecognised celiac disease in all people with eating disorder, especially if they present any gastrointestinal symptom (such as decreased appetite, abdominal pain, bloating, distension, vomiting, diarrhoea or constipation), weight loss, or growth failure; and also routinely ask celiac patients about weight or body shape concerns, dieting or vomiting for weight control, to evaluate the possible presence of eating disorders, specially in women.

Environmental Influences

Child Maltreatment

Child abuse which encompasses physical, psychological and sexual abuse, as well as neglect has been shown to approximately triple the risk of an eating disorder. Sexual abuse appears to about double the risk of bulimia; however, the association is less clear for anorexia.

Social Isolation

Social isolation has been shown to have a deleterious effect on an individual’s physical and emotional well-being. Those that are socially isolated have a higher mortality rate in general as compared to individuals that have established social relationships. This effect on mortality is markedly increased in those with pre-existing medical or psychiatric conditions, and has been especially noted in cases of coronary heart disease. “The magnitude of risk associated with social isolation is comparable with that of cigarette smoking and other major biomedical and psychosocial risk factors.”

Social isolation can be inherently stressful, depressing and anxiety-provoking. In an attempt to ameliorate these distressful feelings an individual may engage in emotional eating in which food serves as a source of comfort. The loneliness of social isolation and the inherent stressors thus associated have been implicated as triggering factors in binge eating as well.

Waller, Kennerley and Ohanian (2007) argued that both bingeing-vomiting and restriction are emotion suppression strategies, but they are just utilised at different times. For example, restriction is used to pre-empt any emotion activation, while bingeing-vomiting is used after an emotion has been activated.

Parental Influence

Parental influence has been shown to be an intrinsic component in the development of eating behaviours of children. This influence is manifested and shaped by a variety of diverse factors such as familial genetic predisposition, dietary choices as dictated by cultural or ethnic preferences, the parents’ own body shape and eating patterns, the degree of involvement and expectations of their children’s eating behaviour as well as the interpersonal relationship of parent and child. This is in addition to the general psychosocial climate of the home and the presence or absence of a nurturing stable environment. It has been shown that maladaptive parental behaviour has an important role in the development of eating disorders. As to the more subtle aspects of parental influence, it has been shown that eating patterns are established in early childhood and that children should be allowed to decide when their appetite is satisfied as early as the age of two. A direct link has been shown between obesity and parental pressure to eat more.

Coercive tactics in regard to diet have not been proven to be efficacious in controlling a child’s eating behaviour. Affection and attention have been shown to affect the degree of a child’s finickiness and their acceptance of a more varied diet. finickity

Adams and Crane (1980), have shown that parents are influenced by stereotypes that influence their perception of their child’s body. The conveyance of these negative stereotypes also affects the child’s own body image and satisfaction. Hilde Bruch, a pioneer in the field of studying eating disorders, asserts that anorexia nervosa often occurs in girls who are high achievers, obedient, and always trying to please their parents. Their parents have a tendency to be over-controlling and fail to encourage the expression of emotions, inhibiting daughters from accepting their own feelings and desires. Adolescent females in these overbearing families lack the ability to be independent from their families, yet realize the need to, often resulting in rebellion. Controlling their food intake may make them feel better, as it provides them with a sense of control.

Peer Pressure

In various studies such as one conducted by The McKnight Investigators, peer pressure was shown to be a significant contributor to body image concerns and attitudes toward eating among subjects in their teens and early twenties.

Eleanor Mackey and co-author, Annette M. La Greca of the University of Miami, studied 236 teen girls from public high schools in southeast Florida. “Teen girls’ concerns about their own weight, about how they appear to others and their perceptions that their peers want them to be thin are significantly related to weight-control behavior”, says psychologist Eleanor Mackey of the Children’s National Medical Centre in Washington and lead author of the study. “Those are really important.”

According to one study, 40% of 9- and 10-year-old girls are already trying to lose weight. Such dieting is reported to be influenced by peer behaviour, with many of those individuals on a diet reporting that their friends also were dieting. The number of friends dieting and the number of friends who pressured them to diet also played a significant role in their own choices.

Elite athletes have a significantly higher rate in eating disorders. Female athletes in sports such as gymnastics, ballet, diving, etc. are found to be at the highest risk among all athletes. Women are more likely than men to acquire an eating disorder between the ages of 13-25. 0-15% of those with bulimia and anorexia are men.

Other psychological problems that could possibly create an eating disorder such as Anorexia Nervosa are depression, and low self-esteem. Depression is a state of mind where emotions are unstable causing a person’s eating habits to change due to sadness and no interest of doing anything. According to PSYCOM “Studies show that a high percentage of people with an eating disorder will experience depression.” Depression is a state of mind where people seem to refuge without being able to get out of it. A big factor of this can affect people with their eating and this can mostly affect teenagers. Teenagers are big candidates for Anorexia for the reason that during the teenage years, many things start changing and they start to think certain ways. According to Life Works an article about eating disorders “People of any age can be affected by pressure from their peers, the media and even their families but it is worse when you’re a teenager at school.” Teenagers can develop eating disorder such as Anorexia due to peer pressure which can lead to Depression. Many teens start off this journey by feeling pressure for wanting to look a certain way of feeling pressure for being different. This brings them to finding the result in eating less and soon leading to Anorexia which can bring big harms to the physical state.

Cultural Pressure

Western Perspective

There is a cultural emphasis on thinness which is especially pervasive in western society. A child’s perception of external pressure to achieve the ideal body that is represented by the media predicts the child’s body image dissatisfaction, body dysmorphic disorder and an eating disorder. “The cultural pressure on men and women to be ‘perfect’ is an important predisposing factor for the development of eating disorders”. Further, when women of all races base their evaluation of their self upon what is considered the culturally ideal body, the incidence of eating disorders increases.

Socioeconomic status (SES) has been viewed as a risk factor for eating disorders, presuming that possessing more resources allows for an individual to actively choose to diet and reduce body weight. Some studies have also shown a relationship between increasing body dissatisfaction with increasing SES. However, once high socioeconomic status has been achieved, this relationship weakens and, in some cases, no longer exists.

The media plays a major role in the way in which people view themselves. Countless magazine ads and commercials depict thin celebrities like Lindsay Lohan, Nicole Richie, Victoria Beckham and Mary Kate Olsen, who appear to gain nothing but attention from their looks. Society has taught people that being accepted by others is necessary at all costs. Unfortunately this has led to the belief that in order to fit in one must look a certain way. Televised beauty competitions such as the Miss America Competition contribute to the idea of what it means to be beautiful because competitors are evaluated on the basis of their opinion.

In addition to socioeconomic status being considered a cultural risk factor so is the world of sports. Athletes and eating disorders tend to go hand in hand, especially the sports where weight is a competitive factor. Gymnastics, horse back riding, wrestling, body building, and dancing are just a few that fall into this category of weight dependent sports. Eating disorders among individuals that participate in competitive activities, especially women, often lead to having physical and biological changes related to their weight that often mimic prepubescent stages. Oftentimes as women’s bodies change they lose their competitive edge which leads them to taking extreme measures to maintain their younger body shape. Men often struggle with binge eating followed by excessive exercise while focusing on building muscle rather than losing fat, but this goal of gaining muscle is just as much an eating disorder as obsessing over thinness. The following statistics taken from Susan Nolen-Hoeksema’s book, (ab)normal psychology, show the estimated percentage of athletes that struggle with eating disorders based on the category of sport.

  • Aesthetic sports (dance, figure skating, gymnastics): 35%.
  • Weight dependent sports (judo, wrestling): 29%.
  • Endurance sports (cycling, swimming, running): 20%.
  • Technical sports (golf, high jumping): 14%.
  • Ball game sports (volleyball, soccer): 12%.

Although most of these athletes develop eating disorders to keep their competitive edge, others use exercise as a way to maintain their weight and figure. This is just as serious as regulating food intake for competition. Even though there is mixed evidence showing at what point athletes are challenged with eating disorders, studies show that regardless of competition level all athletes are at higher risk for developing eating disorders that non-athletes, especially those that participate in sports where thinness is a factor.

Pressure from society is also seen within the homosexual community. Gay men are at greater risk of eating disorder symptoms than heterosexual men. Within the gay culture, muscularity gives the advantages of both social and sexual desirability and also power. These pressures and ideas that another homosexual male may desire a mate who is thinner or muscular can possibly lead to eating disorders. The higher eating disorder symptom score reported, the more concern about how others perceive them and the more frequent and excessive exercise sessions occur. High levels of body dissatisfaction are also linked to external motivation to working out and old age; however, having a thin and muscular body occurs within younger homosexual males than older.

Most of the cross-cultural studies use definitions from the DSM-IV-TR, which has been criticised as reflecting a Western cultural bias. Thus, assessments and questionnaires may not be constructed to detect some of the cultural differences associated with different disorders. Also, when looking at individuals in areas potentially influenced by Western culture, few studies have attempted to measure how much an individual has adopted the mainstream culture or retained the traditional cultural values of the area. Lastly, the majority of the cross-cultural studies on eating disorders and body image disturbances occurred in Western nations and not in the countries or regions being examined.

While there are many influences to how an individual processes their body image, the media does play a major role. Along with the media, parental influence, peer influence, and self-efficacy beliefs also play a large role in an individual’s view of themselves. The way the media presents images can have a lasting effect on an individual’s perception of their body image. Eating disorders are a worldwide issue and while women are more likely to be affected by an eating disorder it still affects both genders (Schwitzer 2012). The media influences eating disorders whether shown in a positive or negative light, it then has a responsibility to use caution when promoting images that projects an ideal that many turn to eating disorders to attain.

To try to address unhealthy body image in the fashion world, in 2015, France passed a law requiring models to be declared healthy by a doctor to participate in fashion shows. It also requires re-touched images to be marked as such in magazines.

There is a relationship between “thin ideal” social media content and body dissatisfaction and eating disorders among young adult women, especially in the Western hemisphere. New research points to an “internalisation” of distorted images online, as well as negative comparisons among young adult women. Most studies have been based in the US, the UK and Australia, these are places where the thin ideal is strong among women, as well as the strive for the “perfect” body.

In addition to mere media exposure, there is an online “pro-eating disorder” community. Through personal blogs and Twitter, this community promotes eating disorders as a “lifestyle”, and continuously posts pictures of emaciated bodies, and tips on how to stay thin. The hashtag “#proana” (pro-anorexia), is a product of this community, as well as images promoting weight loss, tagged with the term “thinspiration”. According to social comparison theory, young women have a tendency to compare their appearance to others, which can result in a negative view of their own bodies and altering of eating behaviours, that in turn can develop disordered eating behaviours.

When body parts are isolated and displayed in the media as objects to be looked at, it is called objectification, and women are affected most by this phenomenon. Objectification increases self-objectification, where women judge their own body parts as a mean of praise and pleasure for others. There is a significant link between self-objectification, body dissatisfaction, and disordered eating, as the beauty ideal is altered through social media.

Although eating disorders are typically under diagnosed in people of colour, they still experience eating disorders in great numbers. It is thought that the stress that those of colour face in the US from being multiply marginalised may contribute to their rates of eating disorders. Eating disorders, for these women, may be a response to environmental stressors such as racism, abuse and poverty.

African Perspective

In the majority of many African communities, thinness is generally not seen as an ideal body type and most pressure to attain a slim figure may stem from influence or exposure to Western culture and ideology. Traditional African cultural ideals are reflected in the practice of some health professionals; in Ghana, pharmacists sell appetite stimulants to women who desire to, as Ghanaians stated, “grow fat”. Girls are told that if they wish to find a partner and birth children they must gain weight. On the contrary, there are certain taboos surrounding a slim body image, specifically in West Africa. Lack of body fat is linked to poverty and HIV/AIDS.

However, the emergence of Western and European influence, specifically with the introduction of such fashion and modelling shows and competitions, is changing certain views among body acceptance, and the prevalence of eating disorders has consequently increased. This acculturation is also related to how South Africa is concurrently undergoing rapid, intense urbanisation. Such modern development is leading to cultural changes, and professionals cite rates of eating disorders in this region will increase with urbanisation, specifically with changes in identity, body image, and cultural issues. Further, exposure to Western values through private Caucasian schools or caretakers is another possible factor related to acculturation which may be associated with the onset of eating disorders.

Other factors which are cited to be related to the increasing prevalence of eating disorders in African communities can be related to sexual conflicts, such as psychosexual guilt, first sexual intercourse, and pregnancy. Traumatic events which are related to both family (i.e. parental separation) and eating related issues are also cited as possible effectors. Religious fasting, particularly around times of stress, and feelings of self-control are also cited as determinants in the onset of eating disorders.

Asian Perspective

The West plays a role in Asia’s economic development via foreign investments, advanced technologies joining financial markets, and the arrival of American and European companies in Asia, especially through outsourcing manufacturing operations. This exposure to Western culture, especially the media, imparts Western body ideals to Asian society, termed Westernisation. In part, Westernisation fosters eating disorders among Asian populations. However, there are also country-specific influences on the occurrence of eating disorders in Asia.

China

In China as well as other Asian countries, Westernization, migration from rural to urban areas, after-effects of sociocultural events, and disruptions of social and emotional support are implicated in the emergence of eating disorders. In particular, risk factors for eating disorders include higher socioeconomic status, preference for a thin body ideal, history of child abuse, high anxiety levels, hostile parental relationships, jealousy towards media idols, and above-average scores on the body dissatisfaction and interoceptive awareness sections of the Eating Disorder Inventory. Similarly to the West, researchers have identified the media as a primary source of pressures relating to physical appearance, which may even predict body change behaviours in males and females.

Fiji

While colonised by the British in 1874, Fiji kept a large degree of linguistic and cultural diversity which characterised the ethnic Fijian population. Though gaining independence in 1970, Fiji has rejected Western, capitalist values which challenged its mutual trusts, bonds, kinships and identity as a nation. Similar to studies conducted on Polynesian groups, ethnic Fijian traditional aesthetic ideals reflected a preference for a robust body shape; thus, the prevailing ‘pressure to be slim,’ thought to be associated with diet and disordered eating in many Western societies was absent in traditional Fiji. Additionally, traditional Fijian values would encourage a robust appetite and a widespread vigilance for and social response to weight loss. Individual efforts to reshape the body by dieting or exercise, thus traditionally was discouraged.

However, studies conducted in 1995 and 1998 both demonstrated a link between the introduction of television in the country, and the emergence of eating disorders in young adolescent ethnic Fijian girls. Through the quantitative data collected in these studies there was found to be a significant increase in the prevalence of two key indicators of disordered eating: self-induced vomiting and high Eating Attitudes Test-26. These results were recorded following prolonged television exposure in the community, and an associated increase in the percentage of households owning television sets. Additionally, qualitative data linked changing attitudes about dieting, weight loss and aesthetic ideas in the peer environment to Western media images. The impact of television was especially profound given the longstanding social and cultural traditions that had previously rejected the notions of dieting, purging and body dissatisfaction in Fiji. Additional studies in 2011 found that social network media exposure, independent of direct media and other cultural exposures, was also associated with eating pathology.

Hong Kong

From the early- to-mid-1990s, a variant form of anorexia nervosa was identified in Hong Kong. This variant form did not share features of anorexia in the West, notably “fat-phobia” and distorted body image. Patients attributed their restrictive food intake to somatic complaints, such as epigastric bloating, abdominal or stomach pain, or a lack of hunger or appetite. Compared to Western patients, individuals with this variant anorexia demonstrated bulimic symptoms less frequently and tended to have lower pre-morbid body mass index. This form disapproves the assumption that a “fear of fatness or weight gain” is the defining characteristic of individuals with anorexia nervosa.

India

In the past, the available evidence did not suggest that unhealthy weight loss methods and eating disordered behaviours are common in India as proven by stagnant rates of clinically diagnosed eating disorders. However, it appears that rates of eating disorders in urban areas of India are increasing based on surveys from psychiatrists who were asked whether they perceived eating disorders to be a “serious clinical issue” in India. 23.5% of respondents believed that rates of eating disorders were rising in Bangalore, 26.5% claimed that rates were stagnant, and 42%, the largest percentage, expressed uncertainty. It has been suggested that urbanisation and socioeconomic status are associated with increased risk for body weight dissatisfaction. However, due to the physical size of and diversity within India, trends may vary throughout the country.

Mechanisms

  • Biochemical:
    • Eating behaviour is a complex process controlled by the neuroendocrine system, of which the Hypothalamus-pituitary-adrenal-axis (HPA axis) is a major component.
    • Dysregulation of the HPA axis has been associated with eating disorders, such as irregularities in the manufacture, amount or transmission of certain neurotransmitters, hormones or neuropeptides and amino acids such as homocysteine, elevated levels of which are found in AN and BN as well as depression.
      • Serotonin: a neurotransmitter involved in depression also has an inhibitory effect on eating behaviour.
      • Norepinephrine is both a neurotransmitter and a hormone; abnormalities in either capacity may affect eating behaviour.
      • Dopamine: which in addition to being a precursor of norepinephrine and epinephrine is also a neurotransmitter which regulates the rewarding property of food.
      • Neuropeptide Y also known as NPY is a hormone that encourages eating and decreases metabolic rate.
        • Blood levels of NPY are elevated in patients with anorexia nervosa, and studies have shown that injection of this hormone into the brain of rats with restricted food intake increases their time spent running on a wheel.
        • Normally the hormone stimulates eating in healthy patients, but under conditions of starvation it increases their activity rate, probably to increase the chance of finding food.
        • The increased levels of NPY in the blood of patients with eating disorders can in some ways explain the instances of extreme over-exercising found in most anorexia nervosa patients.
  • Leptin and ghrelin:
    • Leptin is a hormone produced primarily by the fat cells in the body; it has an inhibitory effect on appetite by inducing a feeling of satiety.
    • Ghrelin is an appetite inducing hormone produced in the stomach and the upper portion of the small intestine.
    • Circulating levels of both hormones are an important factor in weight control.
    • While often associated with obesity, both hormones and their respective effects have been implicated in the pathophysiology of anorexia nervosa and bulimia nervosa.
    • Leptin can also be used to distinguish between constitutional thinness found in a healthy person with a low BMI and an individual with anorexia nervosa.
  • Gut bacteria and immune system:
    • Studies have shown that a majority of patients with anorexia and bulimia nervosa have elevated levels of autoantibodies that affect hormones and neuropeptides that regulate appetite control and the stress response.
    • There may be a direct correlation between autoantibody levels and associated psychological traits.
    • Later study revealed that autoantibodies reactive with alpha-MSH are, in fact, generated against ClpB, a protein produced by certain gut bacteria e.g. Escherichia coli. ClpB protein was identified as a conformational antigen-mimetic of alpha-MSH.
    • In patients with eating disorders plasma levels of anti-ClpB IgG and IgM correalated with patients’ psychological traits
  • Infection:
    • PANDAS, is an abbreviation for Paediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal Infections.
    • Children with PANDAS “have obsessive-compulsive disorder (OCD) and/or tic disorders such as Tourette syndrome, and in whom symptoms worsen following infections such as “strep throat” and scarlet fever”.
    • There is a possibility that PANDAS may be a precipitating factor in the development of anorexia nervosa in some cases, (PANDAS AN).
  • Lesions:
    • Studies have shown that lesions to the right frontal lobe or temporal lobe can cause the pathological symptoms of an eating disorder.
  • Tumours:
    • Tumours in various regions of the brain have been implicated in the development of abnormal eating patterns.
  • Brain calcification:
    • A study highlights a case in which prior calcification of the right thalumus may have contributed to development of anorexia nervosa.
  • Somatosensory homunculus:
    • This is the representation of the body located in the somatosensory cortex, first described by renowned neurosurgeon Wilder Penfield.
    • The illustration was originally termed “Penfield’s Homunculus”, homunculus meaning little man.
    • “In normal development this representation should adapt as the body goes through its pubertal growth spurt.
    • However, in AN it is hypothesized that there is a lack of plasticity in this area, which may result in impairments of sensory processing and distortion of body image”. (Bryan Lask, also proposed by VS Ramachandran).
  • Obstetric complications:
    • There have been studies done which show maternal smoking, obstetric and perinatal complications such as maternal anaemia, very pre-term birth (less than 32 weeks), being born small for gestational age, neonatal cardiac problems, preeclampsia, placental infarction and sustaining a cephalhaematoma at birth increase the risk factor for developing either anorexia nervosa or bulimia nervosa.
    • Some of this developmental risk as in the case of placental infarction, maternal anaemia and cardiac problems may cause intrauterine hypoxia, umbilical cord occlusion or cord prolapse may cause ischemia, resulting in cerebral injury, the prefrontal cortex in the foetus and neonate is highly susceptible to damage as a result of oxygen deprivation which has been shown to contribute to executive dysfunction, ADHD, and may affect personality traits associated with both eating disorders and comorbid disorders such as impulsivity, mental rigidity and obsessionality.
    • The problem of perinatal brain injury, in terms of the costs to society and to the affected individuals and their families, is extraordinary.
  • Symptom of starvation:
    • Evidence suggests that the symptoms of eating disorders are actually symptoms of the starvation itself, not of a mental disorder.
    • In a study involving thirty-six healthy young men that were subjected to semi-starvation, the men soon began displaying symptoms commonly found in patients with eating disorders.
    • In this study, the healthy men ate approximately half of what they had become accustomed to eating and soon began developing symptoms and thought patterns (preoccupation with food and eating, ritualistic eating, impaired cognitive ability, other physiological changes such as decreased body temperature) that are characteristic symptoms of anorexia nervosa.
    • The men used in the study also developed hoarding and obsessive collecting behaviours, even though they had no use for the items, which revealed a possible connection between eating disorders and obsessive compulsive disorder.

Diagnosis

The initial diagnosis should be made by a competent medical professional. “The medical history is the most powerful tool for diagnosing eating disorders”. There are many medical disorders that mimic eating disorders and comorbid psychiatric disorders. Early detection and intervention can assure a better recovery and can improve a lot the quality of life of these patients. All organic causes should be ruled out prior to a diagnosis of an eating disorder or any other psychiatric disorder. In the past 30 years eating disorders have become increasingly conspicuous and it is uncertain whether the changes in presentation reflect a true increase. Anorexia nervosa and bulimia nervosa are the most clearly defined subgroups of a wider range of eating disorders. Many patients present with subthreshold expressions of the two main diagnoses: others with different patterns and symptoms.

It is essential to develop specific scales for people under 18 years of age, given the increasing incidence of ED among children and the need for early detection and appropriate intervention. Early detection of ED in children implies a simple and accurate evaluation at the primary care level or in schools, as the course of the disease can be sub clinical for several years. Moreover, the need for accurate scales and tele-medicine testing and diagnosis is of high importance during the COVID-19 pandemic as youth are at particular risk being psychologically affected due to disrupted education and social interactions – at a critical time.

As eating disorders, especially anorexia nervosa, are thought of as being associated with young, white females, diagnosis of eating disorders in other races happens more rarely. In one study, when clinicians were presented with identical case studies demonstrating disordered eating symptoms in Black, Hispanic, and white women, 44% noted the white woman’s behaviour as problematic; 41% identified the Hispanic woman’s behaviour as problematic, and only 17% of the clinicians noted the Black woman’s behaviour as problematic.

Medical

The diagnostic workup typically includes complete medical and psychosocial history and follows a rational and formulaic approach to the diagnosis. Neuroimaging using fMRI, MRI, PET and SPECT scans have been used to detect cases in which a lesion, tumour or other organic condition has been either the sole causative or contributory factor in an eating disorder. “Right frontal intracerebral lesions with their close relationship to the limbic system could be causative for eating disorders, we therefore recommend performing a cranial MRI in all patients with suspected eating disorders”, “intracranial pathology should also be considered however certain is the diagnosis of early-onset anorexia nervosa. Second, neuroimaging plays an important part in diagnosing early-onset anorexia nervosa, both from a clinical and a research prospective”.

Psychological

After ruling out organic causes and the initial diagnosis of an eating disorder being made by a medical professional, a trained mental health professional aids in the assessment and treatment of the underlying psychological components of the eating disorder and any comorbid psychological conditions. The clinician conducts a clinical interview and may employ various psychometric tests. Some are general in nature while others were devised specifically for use in the assessment of eating disorders. Some of the general tests that may be used are the Hamilton Depression Rating Scale and the Beck Depression Inventory. longitudinal research showed that there is an increase in chance that a young adult female would develop bulimia due to their current psychological pressure and as the person ages and matures, their emotional problems change or are resolved and then the symptoms decline.

Several types of scales are currently used:

  • Self-report questionnaires – EDI-3, BSQ, TFEQ, MAC, BULIT-R, QEWP-R, EDE-Q, EAT, NEQ – and other;
  • Semi-structured interviews – SCID-I, EDE – and other; and
  • Clinical interviews unstructured or observer-based rating scales – Morgan Russel scale.

The majority of the scales used were described and used in adult populations. From all the scales evaluated and analysed, only three are described at the child population – it is EAT-26 (children above 16 years), EDI-3 (children above 13 years), and ANSOCQ (children above 13 years). It is essential to develop specific scales for people under 18 years of age, given the increasing incidence of ED among children and the need for early detection and appropriate intervention. Moreover, the urgent need for accurate scales and telemedicine testing and diagnosis tools are of high importance during the COVID-19 pandemic.

Eating Disorder Specific Psychometric Tests

  • Eating Attitudes Test.
  • Body Attitudes Test.
  • Eating Disorder Inventory.
  • SCOFF Questionnaire.
  • Body Attitudes Questionnaire.
  • Eating Disorder Examination Interview.

Differential Diagnosis

There are multiple medical conditions which may be misdiagnosed as a primary psychiatric disorder, complicating or delaying treatment. These may have a synergistic effect on conditions which mimic an eating disorder or on a properly diagnosed eating disorder.

  • Lyme disease is known as the “great imitator”, as it may present as a variety of psychiatric or neurological disorders including anorexia nervosa.
  • Gastrointestinal diseases, such as celiac disease, Crohn’s disease, peptic ulcer, eosinophilic esophagitis or non-celiac gluten sensitivity, among others.
    • Celiac disease is also known as the “great imitator”, because it may involve several organs and cause an extensive variety of non-gastrointestinal symptoms, such as psychiatric and neurological disorders, including anorexia nervosa.
  • Addison’s disease is a disorder of the adrenal cortex which results in decreased hormonal production. Addison’s disease, even in subclinical form may mimic many of the symptoms of anorexia nervosa.
  • Gastric adenocarcinoma is one of the most common forms of cancer in the world.
    • Complications due to this condition have been misdiagnosed as an eating disorder.
  • Hypothyroidism, hyperthyroidism, hypoparathyroidism and hyperparathyroidism may mimic some of the symptoms of, can occur concurrently with, be masked by or exacerbate an eating disorder.
  • Toxoplasma seropositivity: even in the absence of symptomatic toxoplasmosis, toxoplasma gondii exposure has been linked to changes in human behaviour and psychiatric disorders including those comorbid with eating disorders such as depression.
    • In reported case studies the response to antidepressant treatment improved only after adequate treatment for toxoplasma.
  • Neurosyphilis: It is estimated that there may be up to one million cases of untreated syphilis in the US alone.
    • “The disease can present with psychiatric symptoms alone, psychiatric symptoms that can mimic any other psychiatric illness”.
    • Many of the manifestations may appear atypical.
    • Up to 1.3% of short term psychiatric admissions may be attributable to neurosyphilis, with a much higher rate in the general psychiatric population.
  • Dysautonomia: a wide variety of autonomic nervous system (ANS) disorders may cause a wide variety of psychiatric symptoms including anxiety, panic attacks and depression.
    • Dysautonomia usually involves failure of sympathetic or parasympathetic components of the ANS system but may also include excessive ANS activity.
    • Dysautonomia can occur in conditions such as diabetes and alcoholism.

Psychological disorders which may be confused with an eating disorder, or be co-morbid with one:

  • Emetophobia is an anxiety disorder characterised by an intense fear of vomiting.
    • A person so afflicted may develop rigorous standards of food hygiene, such as not touching food with their hands.
    • They may become socially withdrawn to avoid situations which in their perception may make them vomit.
    • Many who have emetophobia are diagnosed with anorexia or self-starvation.
    • In severe cases of emetophobia they may drastically reduce their food intake.
  • Phagophobia is an anxiety disorder characterized by a fear of eating, it is usually initiated by an adverse experience while eating such as choking or vomiting.
    • Persons with this disorder may present with complaints of pain while swallowing.
  • Body dysmorphic disorder (BDD) is listed as a somatoform disorder that affects up to 2% of the population. BDD is characterised by excessive rumination over an actual or perceived physical flaw.
    • BDD has been diagnosed equally among men and women.
    • While BDD has been misdiagnosed as anorexia nervosa, it also occurs comorbidly in 39% of eating disorder cases.
    • BDD is a chronic and debilitating condition which may lead to social isolation, major depression and suicidal ideation and attempts.
    • Neuroimaging studies to measure response to facial recognition have shown activity predominately in the left hemisphere in the left lateral prefrontal cortex, lateral temporal lobe and left parietal lobe showing hemispheric imbalance in information processing.
    • There is a reported case of the development of BDD in a 21-year-old male following an inflammatory brain process.
    • Neuroimaging showed the presence of a new atrophy in the frontotemporal region.

Prevention

Prevention aims to promote a healthy development before the occurrence of eating disorders. It also intends early identification of an eating disorder before it is too late to treat. Children as young as ages 5–7 are aware of the cultural messages regarding body image and dieting.[235] Prevention comes in bringing these issues to the light. The following topics can be discussed with young children (as well as teens and young adults).

  • Emotional Bites:
    • A simple way to discuss emotional eating is to ask children about why they might eat besides being hungry.
    • Talk about more effective ways to cope with emotions, emphasizing the value of sharing feelings with a trusted adult.
  • Say No to Teasing:
    • Another concept is to emphasize that it is wrong to say hurtful things about other people’s body sizes.
  • Body Talk:
    • Emphasize the importance of listening to one’s body.
    • That is, eating when you are hungry (not starving) and stopping when you are satisfied (not stuffed).
    • Children intuitively grasp these concepts.
  • Fitness Comes in All Sizes:
    • Educate children about the genetics of body size and the normal changes occurring in the body.
    • Discuss their fears and hopes about growing bigger.
    • Focus on fitness and a balanced diet.

Internet and modern technologies provide new opportunities for prevention. On-line programmes have the potential to increase the use of prevention programmes. The development and practice of prevention programmes via on-line sources make it possible to reach a wide range of people at minimal cost. Such an approach can also make prevention programmes to be sustainable.

Treatment

Treatment varies according to type and severity of eating disorder, and usually more than one treatment option is utilized.[241] Family doctors play an important role in early treatment of people with eating disorders by encouraging those who are also reluctant to see a psychiatrist.[242] Treatment can take place in a variety of different settings such as community programs, hospitals, day programs, and groups.[243] The American Psychiatric Association (APA) recommends a team approach to treatment of eating disorders. The members of the team are usually a psychiatrist, therapist, and registered dietitian, but other clinicians may be included.

That said, some treatment methods are:

  • Cognitive behavioural therapy (CBT), which postulates that an individual’s feelings and behaviours are caused by their own thoughts instead of external stimuli such as other people, situations or events; the idea is to change how a person thinks and reacts to a situation even if the situation itself does not change.
    • Acceptance and commitment therapy: a type of CBT.
    • Cognitive remediation therapy (CRT), a set of cognitive drills or compensatory interventions designed to enhance cognitive functioning.
  • The Maudsley anorexia nervosa treatment for adults (MANTRA), which focuses on addressing rigid information processing styles, emotional avoidance, pro-anorectic beliefs, and difficulties with interpersonal relationships.
    • These four targets of treatment are proposed to be core maintenance factors within the Cognitive-Interpersonal Maintenance Model of anorexia nervosa.
  • Dialectical behaviour therapy.
  • Family therapy including “conjoint family therapy” (CFT), “separated family therapy” (SFT) and Maudsley Family Therapy.
  • Behavioural therapy: focuses on gaining control and changing unwanted behaviours.
  • Interpersonal psychotherapy (IPT).
  • Cognitive Emotional Behaviour Therapy (CEBT)u
  • Art therapyu
  • Nutrition counselling and medical nutrition therapy.
  • Medication:
    • Orlistat is used in obesity treatment.
    • Olanzapine seems to promote weight gain as well as the ability to ameliorate obsessional behaviours concerning weight gain. zinc supplements have been shown to be helpful, and cortisol is also being investigated.
  • Self-help and guided self-help have been shown to be helpful in AN, BN and BED; this includes support groups and self-help groups such as Eating Disorders Anonymous and Overeaters Anonymous.
  • Psychoanalysis.
  • Inpatient care.

Two pharmaceuticals, Prozac and Vyvanse, have been approved by the FDA to treat bulimia nervosa and binge-eating disorder, respectively. Olanzapine has also been used off-label to treat anorexia nervosa. Studies are also underway to explore psychedelic and psychedelic-adjacent medicines such as MDMA, psilocybin and ketamine for anorexia nervosa and binge-eating disorder.

There are few studies on the cost-effectiveness of the various treatments. Treatment can be expensive; due to limitations in health care coverage, people hospitalized with anorexia nervosa may be discharged while still underweight, resulting in relapse and rehospitalisation.

For children with anorexia, the only well-established treatment is the family treatment-behaviour. For other eating disorders in children, however, there is no well-established treatments, though family treatment-behaviour has been used in treating bulimia.

A 2019 Cochrane review examined studies comparing the effectiveness of inpatient versus outpatient models of care for eating disorders. Four trials including 511 participants were studied but the review was unable to draw any definitive conclusions as to the superiority of one model over another.

Outcomes

For anorexia nervosa, bulimia nervosa, and binge eating disorder, there is a general agreement that full recovery rates are in the 50% to 85% range, with larger proportions of people experiencing at least partial remission. It can be a lifelong struggle or it can be overcome within months.

  • Miscarriages:
    • Pregnant women with a binge eating disorder have shown to have a greater chance of having a miscarriage compared to pregnant women with any other eating disorders.
    • According to a study done, out of a group of pregnant women being evaluated, 46.7% of the pregnancies ended with a miscarriage in women that were diagnosed with BED, with 23.0% in the control.
    • In the same study, 21.4% of women diagnosed with Bulimia Nervosa had their pregnancies end with miscarriages and only 17.7% of the controls.
  • Relapse:
    • An individual who is in remission from BN and EDNOS (Eating Disorder Not Otherwise Specified) is at a high risk of falling back into the habit of self-harm.
    • Factors such as high stress regarding their job, pressures from society, as well as other occurrences that inflict stress on a person, can push a person back to what they feel will ease the pain.
    • A study tracked a group of selected people that were either diagnosed with BN or EDNOS for 60 months.
    • After the 60 months were complete, the researchers recorded whether or not the person was having a relapse.
    • The results found that the probability of a person previously diagnosed with EDNOS had a 41% chance of relapsing; a person with BN had a 47% chance.
  • Attachment insecurity:
    • People who are showing signs of attachment anxiety will most likely have trouble communicating their emotional status as well as having trouble seeking effective social support.
    • Signs that a person has adopted this symptom include not showing recognition to their caregiver or when he/she is feeling pain.
    • In a clinical sample, it is clear that at the pre-treatment step of a patient’s recovery, more severe eating disorder symptoms directly corresponds to higher attachment anxiety.
    • The more this symptom increases, the more difficult it is to achieve eating disorder reduction prior to treatment.

Anorexia symptoms include the increasing chance of getting osteoporosis. Thinning of the hair as well as dry hair and skin are also very common. The muscles of the heart will also start to change if no treatment is inflicted on the patient. This causes the heart to have an abnormally slow heart rate along with low blood pressure. Heart failure becomes a major consideration when this begins to occur. Muscles throughout the body begin to lose their strength. This will cause the individual to begin feeling faint, drowsy, and weak. Along with these symptoms, the body will begin to grow a layer of hair called lanugo. The human body does this in response to the lack of heat and insulation due to the low percentage of body fat.

Bulimia symptoms include heart problems like an irregular heartbeat that can lead to heart failure and death may occur. This occurs because of the electrolyte imbalance that is a result of the constant binge and purge process. The probability of a gastric rupture increases. A gastric rupture is when there is a sudden rupture of the stomach lining that can be fatal. The acids that are contained in the vomit can cause a rupture in the oesophagus as well as tooth decay. As a result, to laxative abuse, irregular bowel movements may occur along with constipation. Sores along the lining of the stomach called peptic ulcers begin to appear and the chance of developing pancreatitis increases.

Binge eating symptoms include high blood pressure, which can cause heart disease if it is not treated. Many patients recognize an increase in the levels of cholesterol. The chance of being diagnosed with gallbladder disease increases, which affects an individual’s digestive tract.

Risk of Death

Eating disorders result in about 7,000 deaths a year as of 2010, making them the mental illnesses with the highest mortality rate. Anorexia has a risk of death that is increased about 5 fold with 20% of these deaths as a result of suicide. Rates of death in bulimia and other disorders are similar at about a 2 fold increase.

The mortality rate for those with anorexia is 5.4 per 1000 individuals per year. Roughly 1.3 deaths were due to suicide. A person who is or had been in an inpatient setting had a rate of 4.6 deaths per 1000. Of individuals with bulimia about 2 persons per 1000 persons die per year and among those with EDNOS about 3.3 per 1000 people die per year.

Epidemiology

In the developed world, binge eating disorder affects about 1.6% of women and 0.8% of men in a given year. Anorexia affects about 0.4% and bulimia affects about 1.3% of young women in a given year. Up to 4% of women have anorexia, 2% have bulimia, and 2% have binge eating disorder at some point in time. Anorexia and bulimia occur nearly ten times more often in females than males. Typically, they begin in late childhood or early adulthood. Rates of other eating disorders are not clear. Rates of eating disorders appear to be lower in less developed countries.

In the US, twenty million women and ten million men have an eating disorder at least once in their lifetime.

Anorexia

Rates of anorexia in the general population among women aged 11 to 65 ranges from 0 to 2.2% and around 0.3% among men. The incidence of female cases is low in general medicine or specialised consultation in town, ranging from 4.2 and 8.3/100,000 individuals per year. The incidence of AN ranges from 109 to 270/100,000 individuals per year. Mortality varies according to the population considered. AN has one of the highest mortality rates among mental illnesses. The rates observed are 6.2 to 10.6 times greater than that observed in the general population for follow-up periods ranging from 13 to 10 years. Standardised mortality ratios for anorexia vary from 1.36% to 20%.

Bulimia

Bulimia affects females 9 times more often than males. Approximately one to three percent women develop bulimia in their lifetime. About 2% to 3% of women are currently affected in the US. New cases occur in about 12 per 100,000 population per year. The standardised mortality ratios for bulimia is 1% to 3%.

Binge Eating Disorder

Reported rates vary from 1.3 to 30% among subjects seeking weight-loss treatment. Based on surveys, BED appears to affected about 1-2% at some point in their life, with 0.1-1% of people affected in a given year. BED is more common among females than males. There have been no published studies investigating the effects of BED on mortality, although it is comorbid with disorders that are known to increase mortality risks.

Economics

  • Since 2017, the number of cost-effectiveness studies regarding eating disorders appears to be increasing in the past six years.
  • In 2011 US dollars, annual healthcare costs were $1,869 greater among individuals with eating disorders compared to the general population.
    • The added presence of mental health comorbidities was also associated with higher, but not statistically significant, costs difference of $1,993.
  • In 2013 Canadian dollars, the total hospital cost per admission for treatment of anorexia nervosa was $51,349 and the total societal cost was $54,932 based on an average length of stay of 37.9 days.
    • For every unit increase in body mass index, there was also a 15.7% decrease in hospital cost.
  • For Ontario, Canada patients who received specialised inpatient care for an eating disorder both out of country and in province, annual total healthcare costs were about $11 million before 2007 and $6.5 million in the years afterwards.
    • For those treated out of country alone, costs were about $5 million before 2007 and $2 million in the years afterwards.

Can We Improve Diagnosis of Depression with XGBOOST Machine Learning Model & a Large Biomarkers Dutch Dataset?

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Research Paper Title

Improving Diagnosis of Depression With XGBOOST Machine Learning Model and a Large Biomarkers Dutch Dataset ( n = 11,081).

Abstract

Machine Learning has been on the rise and healthcare is no exception to that. In healthcare, mental health is gaining more and more space. The diagnosis of mental disorders is based upon standardised patient interviews with defined set of questions and scales which is a time consuming and costly process.

The objective of the researchers was to apply the machine learning model and to evaluate to see if there is predictive power of biomarkers data to enhance the diagnosis of depression cases.

In this research paper, they aimed to explore the detection of depression cases among the sample of 11,081 Dutch citizen dataset. Most of the earlier studies have balanced datasets wherein the proportion of healthy cases and unhealthy cases are equal but in their study, the dataset contains only 570 cases of self-reported depression out of 11,081 cases hence it is a class imbalance classification problem. The machine learning model built on imbalance dataset gives predictions biased toward majority class hence the model will always predict the case as no depression case even if it is a case of depression.

The researchers used different resampling strategies to address the class imbalance problem. They created multiple samples by under sampling, over sampling, over-under sampling and ROSE sampling techniques to balance the dataset and then, they applied machine learning algorithm “Extreme Gradient Boosting” (XGBoost) on each sample to classify the mental illness cases from healthy cases.

The balanced accuracy, precision, recall and F1 score obtained from over-sampling and over-under sampling were more than 0.90.

Reference

Sharma, A. & Verbeke, W.J.M.I. (2021) Improving Diagnosis of Depression With XGBOOST Machine Learning Model and a Large Biomarkers Dutch Dataset ( n = 11,081). Frontiers in Big Data. doi: 10.3389/fdata.2020.00015. eCollection 2020.

What is World Autism Awareness Day?

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Introduction

World Autism Awareness Day is an internationally recognised day on 02 April every year, encouraging Member States of the United Nations (UN) to take measures to raise awareness about people with autistic spectrum disorders including autism and Asperger syndrome throughout the world.

Background

It was designated by the UN General Assembly resolution (A/RES/62/139).

World Autism Awareness Day”, passed in council on 01 November 2007, and adopted on 18 December 2007. It was proposed by the UN representative from Qatar, Her Highness Sheikha Mozah Bint Nasser Al-Missned, Consort of His Highness Sheikh Hamad Bin Khalifa Al-Thani, the Emir of the State of Qatar, and supported by all member states.

This resolution was passed and adopted without a vote in the UN General Assembly, mainly as a supplement to previous UN initiatives to improve human rights.

World Autism Day is one of only seven official health-specific UN Days. The day itself brings individual autism organisations together all around the world to aid in things like research, diagnoses, treatment, and acceptance for those with a developmental path affected by autism.

Components

The original resolution had four main components:

  • The establishment of the second day of April as World Autism Awareness Day, beginning in 2008.
  • Invitation to Member States and other relevant organisations to the UN or the international societal system, including non-governmental organisations and the private sector, to create initiatives to raise public awareness of autism.
  • Encourages Member States to raise awareness of autism on all levels in society.
  • Asks the UN Secretary-General to deliver this message to member states and all other UN organisations.

Themes

For the past years, each World Autism Awareness Day has focused on a specific theme determined by the UN:

  • 2012: “Launch of Official UN “Awareness Raising” Stamp”.
  • 2013: “Celebrating the ability within the disability of autism”.
  • 2014: “Opening Doors to Inclusive Education”.
  • 2015: “Employment: The Autism Advantage”.
  • 2016: “Autism and the 2030 Agenda: Inclusion and Neurodiversity”.
  • 2017: “Toward Autonomy and Self-Determination”.
  • 2018: “Empowering Women and Girls with Autism”.
  • 2019: “Assistive Technologies, Active Participation”.
  • 2020: “The Transition to Adulthood”.

Notable Initiatives

Onesie Wednesday

In 2014, WAAD coincided with Onesie Wednesday, a day created by the National Autistic Society to encourage people in England, Wales and Northern Ireland to show their support for anyone on the autistic spectrum. By wearing a onesie or pyjamas, participants are saying, “it’s all right to be different”.

Outcomes

United States

In a 2015 Presidential Proclamation, President Obama highlighted some of the initiatives that the US government was taking to bring rights to those with autism and to bring awareness to the disorder. He highlighted things like The Affordable Care Act, which prohibits health insurance companies from denying coverage based on a pre-existing condition such as autism. He also pointed out the recent Autism CARES Act of 2014, which provides higher level training for those who are serving citizens on the autism spectrum.

What is Coping (Psychology)?

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Introduction

Coping means to invest one’s own conscious effort, to solve personal and interpersonal problems, in order to try to master, minimise or tolerate stress and conflict.

The psychological coping mechanisms are commonly termed coping strategies or coping skills. The term coping generally refers to adaptive (constructive) coping strategies, that is, strategies which reduce stress. In contrast, other coping strategies may be coined as maladaptive, if they increase stress. Maladaptive coping is therefore also described, based on its outcome, as non-coping. Furthermore, the term coping generally refers to reactive coping, i.e. the coping response which follows the stressor. This differs from proactive coping, in which a coping response aims to neutralise a future stressor. Subconscious or unconscious strategies (e.g. defence mechanisms) are generally excluded from the area of coping.

The effectiveness of the coping effort depends on the type of stress, the individual, and the circumstances. Coping responses are partly controlled by personality (habitual traits), but also partly by the social environment, particularly the nature of the stressful environment.

Types of Coping Strategies

Hundreds of coping strategies have been identified. Classification of these strategies into a broader architecture has not been agreed upon. Researchers try to group coping responses rationally, empirically by factor analysis, or through a blend of both techniques. In the early days, Folkman and Lazarus split the coping strategies into four groups, namely problem-focused, emotion-focused, support-seeking, and meaning-making coping. Weiten has identified four types of coping strategies:

  1. Appraisal-focused (adaptive cognitive);
  2. Problem-focused (adaptive behavioural);
  3. Emotion-focused; and
  4. Occupation-focused coping.

Billings and Moos added avoidance coping as one of the emotion-focused coping. Some scholars have questioned the psychometric validity of forced categorisation as those strategies are not independent to each other. Besides, in reality, people can adopt multiple coping strategies simultaneously.

Typically, people use a mixture of several coping strategies, which may change over time. All these strategies can prove useful, but some claim that those using problem-focused coping strategies will adjust better to life. Problem-focused coping mechanisms may allow an individual greater perceived control over their problem, whereas emotion-focused coping may sometimes lead to a reduction in perceived control (maladaptive coping).

Lazarus “notes the connection between his idea of ‘defensive reappraisals’ or cognitive coping and Freud’s concept of ‘ego-defenses'”, coping strategies thus overlapping with a person’s defence mechanisms.

Appraisal-Focused Coping Strategies

Appraisal-focused (adaptive cognitive) strategies occur when the person modifies the way they think, for example: employing denial, or distancing oneself from the problem. People may alter the way they think about a problem by altering their goals and values, such as by seeing the humour in a situation: “some have suggested that humor may play a greater role as a stress moderator among women than men”.

Adaptive Behavioural Coping Strategies

People using problem-focused strategies try to deal with the cause of their problem. They do this by finding out information on the problem and learning new skills to manage the problem. Problem-focused coping is aimed at changing or eliminating the source of the stress. The three problem-focused coping strategies identified by Folkman and Lazarus are: taking control, information seeking, and evaluating the pros and cons. However, problem-focused coping may not be necessarily adaptive, especially in the uncontrollable case that one cannot make the problem go away.

Emotion-Focused Coping Strategies

Emotion-focused strategies involve:

  • Releasing pent-up emotions.
  • Distracting oneself.
  • Managing hostile feelings.
  • Meditating.
  • Mindfulness practices.
  • Using systematic relaxation procedures.

Emotion-focused coping “is oriented toward managing the emotions that accompany the perception of stress”. The five emotion-focused coping strategies identified by Folkman and Lazarus are:

  • Disclaiming.
  • Escape-avoidance.
  • Accepting responsibility or blame.
  • Exercising self-control.
  • Positive reappraisal.

Emotion-focused coping is a mechanism to alleviate distress by minimizing, reducing, or preventing, the emotional components of a stressor. This mechanism can be applied through a variety of ways, such as:

  • Seeking social support.
  • Reappraising the stressor in a positive light.
  • Accepting responsibility.
  • Using avoidance.
  • Exercising self-control.
  • Distancing.

The focus of this coping mechanism is to change the meaning of the stressor or transfer attention away from it. For example, reappraising tries to find a more positive meaning of the cause of the stress in order to reduce the emotional component of the stressor. Avoidance of the emotional distress will distract from the negative feelings associated with the stressor. Emotion-focused coping is well suited for stressors that seem uncontrollable (e.g. a terminal illness diagnosis, or the loss of a loved one). Some mechanisms of emotion focused coping, such as distancing or avoidance, can have alleviating outcomes for a short period of time, however they can be detrimental when used over an extended period. Positive emotion-focused mechanisms, such as seeking social support, and positive re-appraisal, are associated with beneficial outcomes. Emotional approach coping is one form of emotion-focused coping in which emotional expression and processing is used to adaptively manage a response to a stressor. Other examples include relaxation training through deep breathing, meditation, yoga, music and art therapy, and aromatherapy, as well as grounding, which uses physical sensations or mental distractions to refocus from the stressor to present.

Reactive and Proactive Coping

Most coping is reactive in that the coping is in response to stressors. Anticipating and reacting to a future stressor is known as proactive coping or future-oriented coping. Anticipation is when one reduces the stress of some difficult challenge by anticipating what it will be like and preparing for how one is going to cope with it.

Social Coping

Social coping recognises that individuals are bedded within a social environment, which can be stressful, but also is the source of coping resources, such as seeking social support from others.

Humour

Humour used as a positive coping strategy may have useful benefits in relation to mental health and well-being. By having a humorous outlook on life, stressful experiences can be and are often minimised.

This coping method corresponds with positive emotional states and is known to be an indicator of mental health. Physiological processes are also influenced within the exercise of humour. For example, laughing may reduce muscle tension, increase the flow of oxygen to the blood, exercise the cardiovascular region, and produce endorphins in the body.

Using humour in coping while processing through feelings can vary depending on life circumstance and individual humour styles. In regards to grief and loss in life occurrences, it has been found that genuine laughs/smiles when speaking about the loss predicted later adjustment and evoked more positive responses from other people. A person of the deceased family member may resort to making jokes of when the deceased person used to give unwanted “wet willies” (term used for when a person sticks their finger inside their mouth then inserts the finger into another person’s ear) to any unwilling participant. A person might also find comedic relief with others around irrational possible outcomes for the deceased funeral service.

It is also possible that humour would be used by people to feel a sense of control over a more powerless situation and used as way to temporarily escape a feeling of helplessness. Exercised humour can be a sign of positive adjustment as well as drawing support and interaction from others around the loss.

Negative Techniques (Maladaptive Coping or Non-Coping)

Whereas adaptive coping strategies improve functioning, a maladaptive coping technique (also termed non-coping) will just reduce symptoms while maintaining or strengthening the stressor. Maladaptive techniques are only effective as a short-term rather than long-term coping process.

Examples of maladaptive behaviour strategies include dissociation, sensitization, safety behaviours, anxious avoidance, rationalisation and escape (including self-medication).

These coping strategies interfere with the person’s ability to unlearn, or break apart, the paired association between the situation and the associated anxiety symptoms. These are maladaptive strategies as they serve to maintain the disorder.

Dissociation is the ability of the mind to separate and compartmentalise thoughts, memories, and emotions. This is often associated with post traumatic stress syndrome.

Sensitization is when a person seeks to learn about, rehearse, and/or anticipate fearful events in a protective effort to prevent these events from occurring in the first place.

Safety behaviours are demonstrated when individuals with anxiety disorders come to rely on something, or someone, as a means of coping with their excessive anxiety.

Rationalisation is the practice of attempting to use reasoning to minimise the severity of an incident, or avoid approaching it in ways that could cause psychological trauma or stress. It most commonly manifests in the form of making excuses for the behaviour of the person engaging in the rationalisation, or others involved in the situation the person is attempting to rationalise.

Anxious avoidance is when a person avoids anxiety provoking situations by all means. This is the most common method.

Escape is closely related to avoidance. This technique is often demonstrated by people who experience panic attacks or have phobias. These people want to flee the situation at the first sign of anxiety.

Further Examples

Further examples of coping strategies include emotional or instrumental support, self-distraction, denial, substance use, self-blame, behavioural disengagement and the use of drugs or alcohol.

Many people think that meditation “not only calms our emotions, but…makes us feel more ‘together'”, as too can “the kind of prayer in which you’re trying to achieve an inner quietness and peace”.

Low-effort syndrome or low-effort coping refers to the coping responses of a person refusing to work hard. For example, a student at school may learn to put in only minimal effort as they believe if they put in effort it could unveil their flaws.

Historical Psychoanalytic Theories

Otto Fenichel

Otto Fenichel summarised early psychoanalytic studies of coping mechanisms in children as “a gradual substitution of actions for mere discharge reactions…[&] the development of the function of judgement” – noting however that “behind all active types of mastery of external and internal tasks, a readiness remains to fall back on passive-receptive types of mastery.”

In adult cases of “acute and more or less ‘traumatic’ upsetting events in the life of normal persons”, Fenichel stressed that in coping, “in carrying out a ‘work of learning’ or ‘work of adjustment’, [s]he must acknowledge the new and less comfortable reality and fight tendencies towards regression, towards the misinterpretation of reality”, though such rational strategies “may be mixed with relative allowances for rest and for small regressions and compensatory wish fulfillment, which are recuperative in effect”.

Karen Horney

In the 1940s, the German Freudian psychoanalyst Karen Horney “developed her mature theory in which individuals cope with the anxiety produced by feeling unsafe, unloved, and undervalued by disowning their spontaneous feelings and developing elaborate strategies of defence.” Horney defined four so-called coping strategies to define interpersonal relations, one describing psychologically healthy individuals, the others describing neurotic states.

The healthy strategy she termed “Moving with” is that with which psychologically healthy people develop relationships. It involves compromise. In order to move with, there must be communication, agreement, disagreement, compromise, and decisions. The three other strategies she described – “Moving toward”, “Moving against” and “Moving away” – represented neurotic, unhealthy strategies people utilise in order to protect themselves.

Horney investigated these patterns of neurotic needs (compulsive attachments). The neurotics might feel these attachments more strongly because of difficulties within their lives. If the neurotic does not experience these needs, they will experience anxiety. The ten needs are:

  • Affection and approval, the need to please others and be liked.
  • A partner who will take over one’s life, based on the idea that love will solve all of one’s problems.
  • Restriction of one’s life to narrow borders, to be undemanding, satisfied with little, inconspicuous; to simplify one’s life.
  • Power, for control over others, for a façade of omnipotence, caused by a desperate desire for strength and dominance.
  • Exploitation of others; to get the better of them.
  • Social recognition or prestige, caused by an abnormal concern for appearances and popularity.
  • Personal admiration.
  • Personal achievement.
  • Self-sufficiency and independence.
  • Perfection and unassailability, a desire to be perfect and a fear of being flawed.

In Compliance, also known as “Moving toward” or the “Self-effacing solution”, the individual moves towards those perceived as a threat to avoid retribution and getting hurt, “making any sacrifice, no matter how detrimental.” The argument is, “If I give in, I won’t get hurt.” This means that: if I give everyone I see as a potential threat whatever they want, I won’t be injured (physically or emotionally). This strategy includes neurotic needs one, two, and three.

In Withdrawal, also known as “Moving away” or the “Resigning solution”, individuals distance themselves from anyone perceived as a threat to avoid getting hurt – “the ‘mouse-hole’ attitude … the security of unobtrusiveness.” The argument is, “If I do not let anyone close to me, I won’t get hurt.” A neurotic, according to Horney desires to be distant because of being abused. If they can be the extreme introvert, no one will ever develop a relationship with them. If there is no one around, nobody can hurt them. These “moving away” people fight personality, so they often come across as cold or shallow. This is their strategy. They emotionally remove themselves from society. Included in this strategy are neurotic needs three, nine, and ten.

In Aggression, also known as the “Moving against” or the “Expansive solution”, the individual threatens those perceived as a threat to avoid getting hurt. Children might react to parental in-differences by displaying anger or hostility. This strategy includes neurotic needs four, five, six, seven, and eight.

Related to the work of Karen Horney, public administration scholars[40] developed a classification of coping by frontline workers when working with clients (see also the work of Michael Lipsky on street-level bureaucracy). This coping classification is focused on the behavior workers can display towards clients when confronted with stress. They show that during public service delivery there are three main families of coping:

  • Moving towards clients:
    • Coping by helping clients in stressful situations.
    • An example is a teacher working overtime to help students.
  • Moving away from clients:
    • Coping by avoiding meaningful interactions with clients in stressful situations.
    • An example is a public servant stating “the office is very busy today, please return tomorrow.”
  • Moving against clients:
    • Coping by confronting clients.
    • For instance, teachers can cope with stress when working with students by imposing very rigid rules, such as no phone use in class and sending everyone to the office when they use a phone.
    • Furthermore, aggression towards clients is also included here.

In their systematic review of 35 years of the literature, the scholars found that the most often used family is moving towards clients (43% of all coping fragments). Moving away from clients was found in 38% of all coping fragments and Moving against clients in 19%.

Heinz Hartmann

In 1937, the psychoanalyst (as well as a physician, psychologist, and psychiatrist) Heinz Hartmann marked it as the evolution of ego psychology by publishing his paper, “Me” (which was later translated into English in 1958, titled, “The Ego and the Problem of Adaptation”). Hartmann focused on the adaptive progression of the ego “through the mastery of new demands and tasks”. In fact, according to his adaptive point of view, once infants were born they have the ability to be able to cope with the demands of their surroundings. In his wake, ego psychology further stressed “the development of the personality and of ‘ego-strengths’…adaptation to social realities”.

Object Relations

Emotional intelligence has stressed the importance of “the capacity to soothe oneself, to shake off rampant anxiety, gloom, or irritability….People who are poor in this ability are constantly battling feelings of distress, while those who excel in it can bounce back far more quickly from life’s setbacks and upsets”. From this perspective, “the art of soothing ourselves is a fundamental life skill; some psychoanalytic thinkers, such as John Bowlby and D. W. Winnicott see this as the most essential of all psychic tools.”

Object relations theory has examined the childhood development both of “[i]ndependent coping…capacity for self-soothing”, and of “[a]ided coping. Emotion-focused coping in infancy is often accomplished through the assistance of an adult.”

Gender Differences

Gender differences in coping strategies are the ways in which men and women differ in managing psychological stress. There is evidence that males often develop stress due to their careers, whereas females often encounter stress due to issues in interpersonal relationships. Early studies indicated that “there were gender differences in the sources of stressors, but gender differences in coping were relatively small after controlling for the source of stressors”; and more recent work has similarly revealed “small differences between women’s and men’s coping strategies when studying individuals in similar situations.”

In general, such differences as exist indicate that women tend to employ emotion-focused coping and the “tend-and-befriend” response to stress, whereas men tend to use problem-focused coping and the “fight-or-flight” response, perhaps because societal standards encourage men to be more individualistic, while women are often expected to be interpersonal. An alternative explanation for the aforementioned differences involves genetic factors. The degree to which genetic factors and social conditioning influence behaviour, is the subject of ongoing debate.

Physiological Basis

Hormones also play a part in stress management. Cortisol, a stress hormone, was found to be elevated in males during stressful situations. In females, however, cortisol levels were decreased in stressful situations, and instead, an increase in limbic activity was discovered. Many researchers believe that these results underlie the reasons why men administer a fight-or-flight reaction to stress; whereas, females have a tend-and-befriend reaction. The “fight-or-flight” response activates the sympathetic nervous system in the form of increased focus levels, adrenaline, and epinephrine. Conversely, the “tend-and-befriend” reaction refers to the tendency of women to protect their offspring and relatives. Although these two reactions support a genetic basis to differences in behaviour, one should not assume that in general females cannot implement “fight-or-flight” behaviour or that males cannot implement “tend-and-befriend” behaviour. Additionally, this study implied differing health impacts for each gender as a result of the contrasting stress-processes.