Assessment of the Residual Issues Regarding Self

Running Head: SELF-CONCEPT AND EATING DISORDERS 1

Assessment of the Residual Issues Regarding Self-Concept in

Adolescents Recovering from an Eating Disorder

Chloe McDaniel

University of Georgia

SELF-CONCEPT AND EATING DISORDERS 2

Abstract

Eating disorders occur primarily in middle to upper class white females during middle

adolescence. The onset of these eating disorders is due mainly to biological and cognitive factors

that have to do with puberty. Eventually relapse rates, the speed at which recovery takes place,

and depression comorbidity all give way to the emotional effects on self-concept during the

recovery process and following an eating disorder.


Assessment of the Residual Issues Regarding Self-Concept in

Adolescents Recovering from an Eating Disorder

Most eating disorders occur in middle to upper class white females for a variety of

reasons. Adolescence is a time when young people, females especially, begin to look at their

bodies more critically because of all of the changes that are occurring during puberty combined

with new cognitive abilities that reveal judgments of other people. Specifically in Western

cultures, the ideal body type for women is a slim figure. Puberty leads to fuller and curvier

bodies which do not meet this ideal. Girls undergoing these physical and biological changes may

feel significant stress to hinder or reverse the effects of puberty by closely monitoring the foods

they eat (Arnett, 2013). Eventually, some young people develop an eating disorder and possibly

multiple eating disorders. Although the DSM-V has certain guidelines to define threshold eating

disorders, there are also adolescents that suffer from subthreshold and partial eating disorders.

The onset of these eating disorders is usually in middle to late adolescence, perhaps when

importance of peer and romantic relationships peak (Stice, Marti, Shaw, & Jaconis, 2009). This

review assesses how recovering from any form of eating disordered behaviors affects the way

these young women and a small portion of men think about themselves. These effects will be

considered with regards to relapse rates, the speed at which recovery takes place, and depression

comorbidity.

Literature Review

Much of the research dedicated to eating disorders centers on relapse rates for

adolescents. Because most eating disorders appear in the form of poor body image

compensation, it can be deduced that relapse occurs due to unresolved problems in the self

following the original eating disorder. Even after hospitalization and inpatient or outpatient


recovery programs, these young people still face the chance of relapse. In a study conducted by

Stice, Marti, Shaw & Jaconis (2009), relapse rates for bulimia nervosa and binge-eating disorder

emerged to be 41% and 33% respectively, the highest observed in their sample. This sample

included threshold as well as subthreshold eating disorders which sheds light on the seriousness

of adolescents exhibiting even a small number of eating disordered behaviors. The fact that there

is strong likelihood of subthreshold or partial disorders to develop into full-scale eating disorders

also lead researchers to further investigate the reasons for and prevention of relapse (Stice, Marti,

Shaw, & Jaconis, 2009). If these youth are spending extensive amounts of time in programs

designed to reduce the possibility of relapse, then why do rates remain so high, and who are the

people most at risk?

While struggling with recovery from an eating disorder, an adolescent can be in a very

vulnerable state physically, mentally, and emotionally. Emotional regulation and impulsivity are

affected in this position. When a sample of women with anorexia nervosa, subtype restrictive

(AN-R) and anorexia nervosa, subtype binge-purge (AN-BP) were inducted into an intensive

inpatient recovery program, patients with AN-R exhibited over controlled emotional regulation

and low impulsiveness, while patients with AN-BP lacked emotional regulatory strategies and

showed signs of high impulsivity (Roswell, MacDonald, & Carter, 2016). The impulsive nature

of adolescents with binge-purge disorders combined with inadequate emotional control leads

them to perceive feelings such as shame and incompetence in a deeper way. Little control of

emotion provokes them to act on their impulsive desires to eat more food and thus to purge the

food. This is strongest during recovery, so relapse is more likely to occur.

Lack of emotional regulation contributes to intensified sentiments of insecurity in one’s

self-concept. Both Thought-Shape Fusion (TSF) and Thought-Action Fusion (TAF) are related to


a belief that bad things will happen if one thinks about them. With regards to TSF, the belief that

thinking about food will cause a person to gain weight, and TAF, the belief that having thoughts

about a negative event increases the likelihood that it will occur, levels are higher in people who

have or have had eating disorders. More specifically, young people who suffer from AN-BP

display higher levels of TSF suggesting they are more susceptible to punishing themselves for

thinking about food, even after recovery (Coelho, Ouellette-Courtois, Purdon, & Steiger, 2015).

The trigger of food-related stimuli may set off a reaction in the person with an eating disorder

that causes him or her to become excessively shameful or guilty which gets out of control due to

lack of emotional regulation abilities. The person may then act on their overwhelming inclination

to revert to their eating disordered behavior. The more emotional distress the adolescent endures,

the higher the chance of regression.

These emotions seem to vary in the setting of an inpatient recovery facility. Eli (2014)

interviewed twelve Israeli women and one man in one of these facilities to study the aspects of

their stay that determined the self-image that the patients had developed throughout. In the

interviews, she discovered several common yet conflicting themes. She highlights battling

between the resisting and finding refuge in an identity of a person with an eating disorder,

deciding whether fellow patients at the ward provide support or risk of relapse, and lastly,

choosing to view the facility as a safe haven or a prison (Eli, 2014). Each of the interviewees felt

both sides of each argument to a different degree. In part, the patients feel that they are

negatively grouped and defined by their eating disorder, but they also feel that the label

legitimizes the sufferings they have undergone. Similarly, although the other patients provided

support and a feeling of belongingness, they had also experienced inklings of jealousy for

patients who had achieved low weights that they had never reached, therefore posing a threat to


each fragile recovery. Many of the patients interviewed had difficulty determining if the facility

took away too many freedoms or if it protected them from the outside world (Eli, 2014). The

attitudes of the patients varied depending on the length of their stays, the number of previous

hospitalizations, and other personal experiences within the facility. The patients who claimed to

have more negative experiences tended to have already relapsed from previous recoveries (Eli,

2014). Perhaps the way a facility encourages the patient to consider himself or herself

contributes to the relapse rate. When a patient has more negative feelings towards the treatment

at an inpatient recovery facility, he or she may be more likely to relapse. Although the study was

conducted in Israel, comparison to British studies of similar topics reveals that the sentiments of

Israeli patients coincide with those of British patients in these types of facilities (Eli, 2014).

A patient centered focal point in recovery from eating disorders leads to appraisal of how

the speed of recovery affects a patient’s personal self-concept. Patients recovering from the

restrictive and binge-purge subtypes of anorexia nervosa see more gradual improvements in their

eating disorder along with their personal body image and self-compassion compared to patients

with bulimia nervosa (BN) and eating disorders not otherwise specified (EDNOS) Additionally,

an adolescent with a case of AN-BP also faces lagging improvements in guilt, warmth of

relationships, and support from others (Kelly & Carter, 2014). Perhaps the findings in Coelho,

Ouellette-Courtois, Purdon, & Steiger’s article on higher TSF and TAF levels in patients with

AN-BP (2015) bestows support to the idea that AN-BP eating disorders often carry difficult

cognitive obstacles to overcome, hence the long recovery time. Subthreshold and partial eating

disorders, which mostly fall under the category of EDNOS, tend to last a shorter amount of time,

about four to five months, rather than the years that threshold eating disorders average to last

(Stice, Marti, Shaw, & Jaconis, 2009). This factor could relate however to the severity of the


eating disorder. When a disorder is more severe, it tends to take longer to recover. The milder

state of a partial or threshold eating disorder may factor into its short existence (Stice, Marti,

Shaw, & Jaconis, 2009).

Because the most severe eating disorders take the longest to recover generally, those

young people suffering from severe forms of anorexia nervosa, bulimia nervosa, or binge eating

disorder especially have faced many difficult cognitive battles against their illness (Stice, Marti,

Shaw, & Jaconis, 2009). Self-talk is the proverbial voice of the eating disorder. This voice takes

on several different personas, a few of which being a seducer, a disciplinarian or coach, a

mentor, and an abuser. Each voice plays a different role in triggering hatred for the body and an

enigmatic need for improvement. The seducer tells the victim of an eating disorder that if she

loses five more pounds, then she will be satisfied. The coach provides strict rules for food intake

and/or exercising and is the source of discipline. The mentor tells the person that being skinny is

morally valued. Having discipline and denying oneself builds character. Finally, the abuser

destroys self-esteem. The degree of self-talk is positively correlated with severity (Scott,

Hanstock, & Thornton, 2014). In other words, those who endure a very severe form of an eating

disorder are markedly more likely to hear stronger voices of their illness telling them that they

are never going to be skinny enough, worthy enough, or even self-sacrificing enough to be

valued by others even during recovery.

These feelings of worthlessness provide evidence that most internalized problems such as

eating disorders have high comorbidity rates with other internalizing issues. Diminished self

worth is a key depressive symptom observed in young people. Because body image and self-

esteem issues go hand in hand with eating disorders, it is almost conservative to state that most

adolescents who suffer from an eating disorder also experience some degree of depression. To


support this notion, one study assessed the success rates in interventions involving both eating

disorders and depressive symptoms (Rodgers & Paxton, 2014). The interventions saw a 92%

success rate in reducing symptoms of eating disorders, yet only 42% of the interventions were

able to relieve eating disorder symptoms as well as depressive symptoms. Because eating

disordered behaviors are nearly three times more prevalent in girls who reported depressive

symptoms in early adolescence, this is essential to the prevention and improvement of eating

disorder symptoms (Allen, Crosby, Oddy, & Byrne, 2013). Even if the eating disorder is

eliminated through treatment, often times, the depressive symptoms remain left behind for the

victim to deal with.

Overall, the suffering and lack of a positive self-concept that accompany an eating

disorder diagnosis do not cease upon recovery. The recovery process as well as the system of

resocialization in the outside world still carries with them feelings of inadequacy, hopelessness,

and shame. Sometimes, adolescents must undergo the course of recovery and relapse several

times before they can fully focus on the negative remnants that plague their minds. Many of

these studies focused on simply eliminating the symptoms of eating disorders alone.

Comorbidity factors rarely appear in the literature, and when they do, the information sheds little

light on possible solutions. Another issue encountered in many studies on eating disorders is

having too small of a sample size. Reliable and valid studies are scattered and scanty. Larger

samples should be selected, perhaps through the educational system, to get more accurate

prevalence and relapse rates and other statistics on adolescents and emerging adults who

experience eating disorders. Relapse back to old eating disordered behaviors is an extremely

serious issue. Yet, the scarcity of literature available on the topic raises the question that asks if

researchers are dedicating most of their efforts to prevention while ignoring intervention


strategies. Nonetheless, eating disorders are odd groupings of psychopathological illnesses that

stump many researchers and interventionists because of their unconventional prevalence in

predominantly middle to upper class white and female populations. They coincide with other

internalizing problems such as depression and anxiety, causing many to ponder which came first

and which should be addressed first. However baffling the issue of eating disorders may be, there

is much more research to be done to alleviate the victims of such a troubling illness.


References

Allen, K. L., Crosby, R. D., Oddy, W. H., & Byrne, S. M. (2013, August 20). Eating disorder

symptom trajectories in adolescence: Effects of time, participant sex, and early

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doi:10.1186/2050-2974-1-32.

Arnett, J. J. (2013). Adolescence and emerging adulthood: A cultural approach (5th ed.). Upper

Saddle River, NJ: Pearson Prentice Hall.

Coelho, J. S., Ouellet-Courtois, C., Purdon, C., & Steiger, H. (2015, September 04).

Susceptibility to cognitive distortions: The role of eating pathology. J Eat Disord Journal

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Eli, K. (2014). Between Difference and Belonging: Configuring Self and Others in Inpatient

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Kelly, A. C., & Carter, J. C. (2014, January 13). Eating disorder subtypes differ in their rates of

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2. doi:10.1186/2050-2974-2-2.

Rodgers, R. F., & Paxton, S. J. (2014, November 13). The impact of indicated prevention and

early intervention on co-morbid eating disorder and depressive symptoms: A systematic

review. J Eat Disord Journal of Eating Disorders, 2(1). doi:10.1186/s40337-014-0030-2.

Rowsell, M., Macdonald, D. E., & Carter, J. C. (2016). Emotion regulation difficulties in

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Scott, N., Hanstock, T. L., & Thornton, C. (2014, May 27). Dysfunctional self-talk associated

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Stice, E., Marti, C. N., Shaw, H., & Jaconis, M. (2009). An 8-Year Longitudinal Study of the

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Assessment of the Residual Issues Regarding Self

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