What kind of illness is anorexia nervosa? Revisited: some preliminary thoughts to finding a cure.

Two decades have elapsed since our publication of 'What kind of illness is anorexia nervosa?'. The question remains whether our understanding of anorexia nervosa and its treatment thereof has evolved over this time. The verdict is disappointing at best. Our current gold standard treatments remain over-valued and clinical outcomes are modest at best. Those in our field are haunted by the constant reminder that anorexia nervosa carries the highest mortality rate of any psychiatric disorder. This cannot continue and demands immediate action. In this essay, we tackle the myths that bedevil our field and explore a deeper phenotyping of anorexia nervosa. We argue that we can no longer declare agnostic views of the disorder or conceive treatments that are "brainless": it is incumbent upon us to challenge the prevailing zeitgeist and reconceptualise anorexia nervosa. Here we provide a roadmap for the future.

The effects of calorie information on food selection and intake.

OBJECTIVES: To examine the effects of calorie labeling on food selection and intake in dieters and non-dieters, and to explore whether expectations about food healthfulness moderate these effects. METHODS: Participants were presented with a menu containing two items, a salad and a pasta dish. The menu had (a) no calorie information, (b) information that the salad was low in calories and the pasta was high in calories, (c) information that the salad was high in calories and the pasta was low in calories or (d) information that both were high in calories (study 2 only). RESULTS: Calorie labels influenced food selection for dieters, but not for non-dieters. Dieters were more likely to order salad when the salad was labeled as low in calories and more likely to order pasta, even high-calorie pasta, when the salad was labeled as high in calories. Participants who chose high-calorie foods over low-calorie foods did not eat less in response to calorie information, although non-dieters reduced their intake somewhat when calorie labels were put in the context of recommended daily calories. CONCLUSIONS: The results suggest that the rush to provide calorie information may not prove to be the best approach to fighting the obesity epidemic.

External cues in the control of food intake in humans: the sensory-normative distinction.

We review the history of "external cues" as an important factor in the control of human food intake. We begin with Schachter's proposal that obese individuals are especially (and perhaps exclusively) responsive to external food cues and examine subsequent modifications and challenges to that model and the decline and resurgence of research on external cues. We introduce a distinction between normative and sensory external cues. Normative cues (e.g., portion size) refer to indicators of appropriate intake, whereas sensory cues (e.g., palatability) refer to the hedonic appeal of the food. We propose that normative cues affect everyone, whereas sensory cues, while affecting everyone, have a more powerful effect on some types of individuals (e.g., the obese) than on others.

Weight-related other evaluation in eating disorders.

Weight-related self-evaluation has been described as the fundamental maladaptive cognitive feature of disordered eating. It is not clear, however, whether the process of determining personal-worth based on an evaluation of body size is specific to the self, or whether it is relevant to the evaluation of people in general. Thirty-three eating disordered patients and 54 undergraduates read an article about a woman who was described as either overweight or slender and evaluated the woman on several dimensions. Both undergraduates and eating disordered patients rated the heavy woman as less attractive than the thin woman. However, the patients' evaluation of the overweight target's attractiveness was significantly more negative than the undergraduates'. Patients also rated the overweight woman as less popular and claimed that they liked the overweight woman less than the thin woman. These effects were not present among the undergraduate students. Finally, the eating disorder participants rated the overweight woman as more overweight and less intelligent than did the undergraduate students. The results suggest that weight-related evaluation in eating disorders extends beyond the self to include the evaluation of other people.

The false hope syndrome: unrealistic expectations of self-change.

People appear to behave paradoxically, by persisting in repeated self-change attempts despite previous failures. It is argued, though, that self-change attempts provide some initial rewards even when unsuccessful. Feelings of control and optimism often accompany the early stages of self-modification efforts. In addition, unrealistic expectations concerning the ease, speed, likely degree of change, and presumed benefits of changing may overwhelm the knowledge of one's prior failures. It is thus important to learn to distinguish between potentially feasible and impossible self-change goals in order to avoid overconfidence and false hopes leading to eventual failure and distress.

Weight-related and shape-related self-evaluation in eating-disordered and non-eating-disordered women.

OBJECTIVE: Weight- and shape-related self-evaluation refers to the process whereby an individual determines her self-worth based on an evaluation of her body weight and shape. This is a hallmark feature of both anorexia and bulimia nervosa, as specified in the 4th ed. of the Diagnostic and Statistical Manual of Mental Disorders. The purpose of this study was to further our understanding of weight-related self-evaluation in eating-disordered women. METHOD: Eating-disordered patients, restrained eaters, and unrestrained eaters completed an experimenter-designed questionnaire that examines different dimensions of weight-related self-evaluation (i.e., the Multidimensional Weight-Related Self-Evaluation Inventory). RESULTS: Results revealed that weight-related self-evaluation is a feature shared, to some extent, by both eating-disordered patients and restrained eaters. However, eating-disordered patients extend weight-related self-evaluation to include more domains of self-esteem than did restrained eaters. DISCUSSION: These findings support a multidimensional approach to weight-related self-evaluation and further our understanding of the process of weight-related self-evaluation in eating-disordered patients.

Self-presentational conflict in social eating situations: a normative perspective.

This study explored the degree to which people adhere to norms for "appropriate" eating behavior in social situations. Of particular interest was how people determine what is appropriate behavior when they are faced with conflicting norms within a given situation. Participants tasted cookies while alone or while observed by the experimenter. Furthermore, participants were assigned to either a "no norm" condition in which they were given no indication of how much other people in the study had eaten, an "inhibition norm" condition in which they were led to believe that others had eaten minimally, or an "augmentation norm" condition in which they were led to believe that others in the study had eaten a lot. When they were alone, participants were influenced by the norms; but when they were observed, they ate minimally, regardless of the norms to which they were exposed. It seems that a norm for minimal eating superseded a matching norm which prescribes that people should use the intake of their peers as a guide for appropriate behavior. Implications of these findings and limitations of the study were discussed.

Eating disorders, dieting, and the accuracy of self-reported weight.

OBJECTIVE: This study investigated the accuracy of self-reported weight and height in individuals with an eating disorder (i.e., anorexia nervosa [AN] and bulimia nervosa [BN]) and in individuals without an eating disorder (i.e., dieters and nondieters). METHOD: Self-reported and measured weights and heights were obtained from the eating disorder sample (n = 81) and the college student sample (n = 163) and were compared within and between the groups. RESULTS: Eating disorder patients were extremely accurate at self-reporting their weight. However, there was a significant difference in accuracy between AN and BN patients. AN patients slightly overreported their weight, whereas BN patients slightly underreported their weight. Both dieters and nondieters significantly underreported their weight. However, dieters significantly underreported their weight to a greater degree than did the nondieters. DISCUSSION: The implications of these subgroup differences and their specificity to weight reporting are discussed with reference to the accuracy of self-reported height.

The effects of resolving to diet on restrained and unrestrained eaters: the "false hope syndrome".

OBJECTIVE: The persistence of dieters' weight loss efforts, despite repeated failures, suggests that there must be some interim reinforcement for dieting that sustains the behavior. We propose that self-change efforts capitalize on a "false hope syndrome," in which the initial commitment to change brings immediate rewards (largely improvements in self-image), regardless of the eventual outcome. METHOD: Eighty female students chose whether they would attempt either to reduce their weight or to increase their study time over a 2-week period. A control group did not attempt self-change. RESULTS: The effects of making a resolution to change differed for novice and veteran self-changers (nondieters and chronic dieters). Nondieters showed an immediate improvement in their mood and self-image after making a resolution, but this subjective improvement dissipated over the course of the study. Veteran dieters showed a mixed response, initially feeling both more depressed, yet more hopeful of success. DISCUSSION: These results are discussed in terms of variations on the false hope syndrome for different kinds of individuals (novices and veterans).

Effects of attentional focus on subjective hunger ratings.

Food-deprived and non-deprived non-dieters rated their hunger and fullness during a <<<>>> period and then during three counterbalanced video presentations-a control video, a video featuring palatable food cues and an absorbing non-food video. The food-cue video increased hunger ratings for both deprived and non-deprived participants. The absorbing non-food video decreased hunger for deprived (but not for non-deprived) participants. Changes in fullness ratings were not simply the complement of changes in hunger ratings. The discussion focuses on the cognitive mediators of hunger perception.

Distress and eating: why do dieters overeat?

OBJECTIVE: It has been shown that distress suppresses eating in nondieters (unrestrained eaters), but increases it in chronic dieters (restrained eaters). This study attempted to investigate several possible explanations for this phenomenon, in particular, the "masking hypothesis." This hypothesis states that dieters use overeating to mask their distress in other areas of their lives by eating when distressed so that they can attribute their distress to their overeating rather than to more uncontrollable aspects of themselves or their lives. In addition, comfort, learned helplessness, and distraction explanations were investigated. METHOD: Female college student subjects were led to believe that they had or had not failed at a cognitive task, then were either given ad libitum or just three small spoonfuls of ice cream to taste and rate. RESULTS: It was predicted that restrained subjects who ate ad libitum following failure would attribute more of their distress to their eating than would those who were allowed only a taste of ice cream. The results were more complicated than predicted. They indicated that the masking, distraction, and helplessness hypotheses all received some support in the present study and that they may work in tandem with each other. DISCUSSION: The results suggest that distress-induced overeating in restrained eaters may serve psychological functions for the individual, allowing for distraction from the distress or masking of the source of dysphoria. The possible relevance of these results to bulimic patients who may use their binges to mask the true source of their distress is discussed.

Effects of false weight feedback on mood, self-evaluation, and food intake in restrained and unrestrained eaters.

Restrained and unrestrained eaters were weighted 5 lb (2.27 kg) heavier or 5 lb lighter than their actual weight or were not weighed at all. Unrestrained eaters and restrained eaters who were told they weighed 5 lb less were not affected by the false weight feedback. However, restrained eaters who were informed that they weighted 5 lb more reported lower self-esteem, less positive moods, and more negative moods than did restrained eaters in the other 2 conditions. Furthermore, restrained eaters who were led to believe that they weighed heavier ate significantly more food during a subsequent "taste test" than did each of the other groups. Restrained eaters who believed that they were heavier experienced lowered self-worth and a worsening of mood that led them to relinquish their dietary restraint and overindulge in available food. Implications for patients with eating disorders are discussed.

Weight gain after smoking cessation in women: the impact of dieting status.

OBJECTIVE: The fear of weight gain appears to be a barrier to quitting in some smokers, particularly in women. However, not all female smokers have the same concerns about weight, and not all quitters are equally susceptible to gaining weight after cessation. We hypothesized that among females, dieters, compared to nondieters, would report more weight gain after smoking cessation and would tend to smoke more for weight control purpose. METHOD: Undergraduate college students were surveyed to assess their smoking status, dieting status, postcessation weight gain, and their motivations to smoke. RESULTS: Among former smokers, dieters reported considerably more weight gain than nondieters. Dieters were more likely to have started, and to have continued smoking in order to control their weight, and among current smokers, dieters reported having had shorter quit attempts. DISCUSSION: The dieters/former smokers' comparatively high weight gain after smoking cessation is discussed in terms of possible changes in dietary intake, metabolic rate, and physical activity.

Weight dissatisfaction and weight loss attempts among Canadian adults. Canadian Heart Health Surveys Research Group.

OBJECTIVE: To describe the pattern of weight dissatisfaction and weight loss attempts among Canadian adults and the reasons for and methods of weight loss among those trying to lose weight. DESIGN: Population-based, cross-sectional surveys. SETTING: Ten Canadian provinces between 1986 and 1992. PARTICIPANTS: A probability sample of 29,855 men and women aged 18 to 74 years was selected using provincial health insurance registration files; this paper describes the subsample of 19,841 (66%) participants from whom anthropometric data were collected. OUTCOME MEASURES: Discrepancy between actual and desired body mass index (BMI); attempts to lose weight; reasons for losing weight; methods of weight loss used. RESULTS: Whether their weight was in the acceptable range (BMI 20-24 kg/m2) or at a level of increasing risk (BMI > or = 27 kg/m2), women were more likely than men to wish they weighed less and to be trying to lose weight; almost two-thirds of women but less than half the men with BMI > or = 27 kg/m2 were trying to lose weight. Even among those with BMI 20-24 kg/m2, 32% of women (v. 10% of men) were trying to reduce their weight. Weight dissatisfaction and current and past weight loss attempts were all negatively associated with age among women, but were unrelated to age among men. People with higher ratios of waist to hip circumference (WHR), controlling for BMI, were no more likely to be trying to lose weight than those with lower WHR; in fact, for women with BMI 27-29 kg/m2, WHR was negatively associated with prevalence of weight loss attempts. The presence of diabetes, hypertension and hypercholesterolemia was also unrelated to weight loss attempts; regular smokers and sedentary people were less likely to report trying to lose weight, controlling for BMI. Among those currently trying to lose weight, the most commonly mentioned reason was to improve general health, followed by increasing attractiveness. Overall, the most frequently mentioned method of weight loss was dieting, followed by exercise. CONCLUSIONS: Substantial numbers of men whose BMI places them at increased health risk appear to be content with their weight and are not attempting to reduce it. Conversely, women, especially the young and middle-aged, are likely to consider themselves above their desired weight and to be trying to lose weight, even when their weight is within acceptable limits. This reinforces the need to consider differences between men and women in efforts to promote and support healthy weights among Canadians.

The effect of pre-exposure to food cues on the eating behavior of restrained and unrestrained eaters.

This study investigated the effect of pre-exposure to two types of food cues (olfactory and cognitive) on food intake by restrained and unrestrained eaters. Subjects were exposed to either no cue, an olfactory cue, a cognitive cue or a combination of the two types of food cues for ten minutes prior to eating. Restrained eaters ate significantly more than did unrestrained eaters after exposure to the food cues. There was no difference in food intake when there was no pre-exposure to the cues. Although baseline subjective ratings were equivalent for both groups of subjects, after cue pre-exposure, restrained subjects, in keeping with their increased consumption, indicated a significantly greater craving, liking, and desire to eat the cued food (pizza) than did the unrestrained subjects. These findings suggest that restrained eaters are more sensitive and reactive to food cues than are unrestrained eaters. The food cues appeared to generate an appetitive urge to eat in restrained eaters.

Psychological consequences of food restriction.

A review of the literature and research on food restriction indicates that inhibiting food intake has consequences that may not have been anticipated by those attempting such restriction. Starvation and self-imposed dieting appear to result in eating binges once food is available and in psychological manifestations such as preoccupation with food and eating, increased emotional responsiveness and dysphoria, and distractibility. Caution is thus advisable in counseling clients to restrict their eating and diet to lose weight, as the negative sequelae may outweigh the benefits of restraining one's eating. Instead, healthful, balanced eating without specific food restrictions should be recommended as a long-term strategy to avoid the perils of restrictive dieting.

Hunger-induced finickiness in humans.

Two experiments were conducted to examine the effect of hunger on finickiness in humans. Subjects (a total of 157 undergraduate female dieters and non-dieters) were food-deprived and then subsequently either given a snack (not-hungry group) or left food-deprived (hungry group) before being given ad libitum access to either good-tasting or bad-tasting (quinine-adultered) milkshake. Common sense predicted that hungry subjects would drink more milkshake than would not-hungry subjects, regardless of milkshake palatability. Hungry subjects did in fact drink more of the good-tasting milkshake than did not-hungry subjects, but they also drank less of the bad-tasting milkshake. We discuss possible reasons why hunger might increase rejection of bad-tasting food, as well as the limiting conditions of the effect.

Coprophagia as a manifestation of obsessive-compulsive disorder: a case report.

Coprophagia is seen, though uncommonly, in psychiatric hospitals among adult patients with diffuse brain disease and in individuals with subaverage intelligence. We describe here a case of coprophagia in an adult with normal cognitive functioning. Thorough assessment revealed that this coprophagia was a manifestation of obsessive-compulsive disorder. The problem behavior responded to a behavioral treatment program comprising exposure and response prevention.

Social facilitation of eating among friends and strangers.

Research suggests that meals eaten with other people are larger than meals eaten alone. The effect of group size and acquaintance on consumption was investigated by serving dinner to female subjects alone, in pairs or in groups of four. Subjects dined alone, with friends or with strangers. Subjects in both pairs and groups of four ate more than did subjects alone, suggesting that the mere presence of others is more important in enhancing intake than the specific number of people present. Subjects with friends ate more dessert than subjects with strangers, indicating that the relationship of dining companions is an important factor contributing to social facilitation.

Effects of anxiety on eating: does palatability moderate distress-induced overeating in dieters?

When confronted with an anxiety-producing threat to self-esteem, restrained eaters (dieters) increase their food consumption. The functional explanation suggests that increased eating temporarily counteracts or masks dysphoria for the restrained eater; externality or stimulus sensitivity theories propose that distress shifts the dieter's attention to external stimulus properties (e.g., taste) and to activities stimulated by such external cues. In an attempt to distinguish between these two explanations, anxious and nonanxious restrained and unrestrained eaters were given palatable and unpalatable foods, and consumption was measured. Results support the functional explanations: Distressed dieters increased their intake of food regardless of taste properties. Theoretical and practical implications for both restrained eating and the behavior of eating disorder patients are discussed.