Eating Disorders

Our bodies are naturally disposed to maintain a steady weight, storing energy reserves in case food becomes unavailable. But psychological influences can overwhelm biological wisdom. Nowhere is this more painfully clear than in eating disorders.

Understanding Eating Disorders

So, how can we explain eating disorders? Heredity matters. Identical twins share these disorders somewhat more often than fraternal twins do (Culbert et al., 2009; Klump et al., 2009; Root et al., 2010). Scientists are searching for culprit genes. Data from 15 studies indicate that having a gene that reduces available serotonin adds 30 percent to a person’s risk of anorexia or bulimia (Calati et al., 2011).

But environment also matters. People with anorexia come from families that tend to be competitive, high-achieving, and protective (Berg et al., 2014; Pate et al., 1992; Yates, 1989, 1990). And people with eating disorders often have low self-esteem, set impossible standards, fret about falling short of expectations, and worry about how others perceive them (Brauhardt et al., 2014; Pieters et al., 2007; Yiend et al., 2014).

Our environment includes our culture and our history. Ideal shapes vary across culture and time. In areas with high rates of poverty—where plump means prosperous and thin can signal poverty or illness—bigger is better (Knickmeyer, 2001; Swami et al., 2010).

Bigger does not seem better in Western cultures, where the rise in eating disorders over the last 50 years has coincided with a dramatic increase in women having a poor body image (Feingold & Mazzella, 1998). Those most vulnerable to eating disorders are also those (usually women or gay men) who most idealize thinness and have the greatest body dissatisfaction (Feldman & Meyer, 2010; Kane, 2010; Stice et al., 2010). Part of the pressure stems from images of unnaturally thin models and celebrities (Tovee et al., 1997). One former model recalled walking into a meeting with her agent, starving and with her organs failing as a result of anorexia (Caroll, 2013). Her agent’s greeting: “Whatever you are doing, keep doing it.”

Should it surprise us, then, that women who view such images often feel ashamed, depressed, and dissatisfied with their own bodies (Myers & Crowther, 2009; Tiggeman & Miller, 2010)? In one study, researchers tested media influences by giving some adolescent girls (but not others) a 15-month subscription to a teen fashion magazine (Stice et al., 2001). Vulnerable magazine readers (girls who felt dissatisfied, idealized thinness, and lacked social support) showed increased body dissatisfaction and eating disorder tendencies.

Some critics point out that there’s much more to body dissatisfaction and anorexia than media effects (Ferguson et al., 2011). Peer influences, such as teasing, also matter. Nevertheless, the sickness of today’s eating disorders stems in part from today’s weight-obsessed culture—a culture that says “Fat is bad” in countless ways.

If cultural learning contributes to eating behavior, could prevention programs increase acceptance of one’s body? Prevention studies answer Yes. They seem especially effective if the programs are interactive and focused on girls over age 15 (Beintner et al., 2012; Melioli et al., 2016; Vocks et al., 2010).

Among the most bewildering disorders are the rare dissociative disorders. The person’s conscious awareness is said to become separated—dissociated—from painful memories, thoughts, and feelings. In this state, people may suddenly lose their memory or change their identity, often in response to an overwhelmingly stressful situation.

Dissociation itself is not so rare. Any one of us may have a fleeting sense of being unreal, of being separated from our body, of watching ourselves as if in a movie. But a massive dissociation of self from ordinary consciousness occurs in dissociative identity disorder (DID—formerly called multiple personality disorder). At different times, two or more distinct identities seem to control the person’s behavior, each with its own voice and mannerisms. Thus, the person may be prim and proper one moment, loud and flirtatious the next. Typically, the original personality denies any awareness of the other(s).

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Skeptics question the genuineness of DID. First, they find it suspicious that DID has such a short history. Between 1930 and 1960, the number of North American DID diagnoses was 2 per decade. By the 1980s, when the DSM contained the first formal code for this disorder, the number had exploded to more than 20,000 (McHugh, 1995b). The average number of displayed personalities also mushroomed—from 3 to 12 per patient (Goff & Simms, 1993).

Second, note skeptics, DID rates vary by culture. It is much less common outside North America, although in other cultures some people are said to be “possessed” by an alien spirit (Aldridge-Morris, 1989; Kluft, 1991). In Britain, DID—which some consider “a wacky American fad” (Cohen, 1995)—is rare. In India and Japan, it is essentially nonexistent (or at least unreported). Such findings, say skeptics, point to a cultural explanation. They propose that this is a disorder exhibited by suggestible, fantasy-prone people, and that it is created by therapists in a particular social context (Giesbrecht et al., 2008, 2010; Lynn et al., 2014; Merskey, 1992).

Third, some skeptics have asked, could DID be an extension of our normal capacity for personality shifts? Perhaps dissociative identities are simply a more extreme version of the varied “selves” we normally present, as when we display a goofy, loud self while hanging out with friends, and a subdued, respectful self around grandparents. If so, say the critics, clinicians who discover multiple personalities may merely have triggered role playing by fantasy-prone people. After all, clients do not enter therapy saying, “Allow me to introduce myselves.” Rather, charge the critics, some therapists go fishing for multiple personalities: “Have you ever felt like another part of you does things you can’t control? Does this part of you have a name? Can I talk to the angry part of you?” Once clients permit a therapist to talk, by name, “to the part of you that says those angry things,” they begin acting out the fantasy. Like actors who lose themselves in their roles, vulnerable people may “become” the parts they are acting out. The result may be the experience of another self.

Other researchers and clinicians believe DID is a real disorder. They cite findings of distinct brain and body states associated with differing personalities (Putnam, 1991). People with DID exhibit increased activity in brain areas linked with the control and inhibition of traumatic memories (Elzinga et al., 2007). Brain scans show shrinkage in other areas that aid memory and threat detection (Vermetten et al., 2006).

Understanding Dissociative Identity Disorder

If DID is a real disorder, how can we best understand it? Both the psychodynamic and the learning perspectives have interpreted DID symptoms as ways of coping with anxiety. Some psychodynamic theorists see them as defenses against the anxiety caused by unacceptable impulses. In this view, a second personality could allow the discharge of forbidden impulses. Learning theorists see dissociative disorders as behaviors reinforced by anxiety reduction.

Some clinicians include dissociative disorders under the umbrella of posttraumatic stress disorder. In this view, DID is a natural, protective response to traumatic experiences during childhood (Dalenberg et al., 2012). Many people with DID recall suffering physical, sexual, or emotional abuse as children (Gleaves, 1996; Lilienfeld et al., 1999). In one study of 12 murderers diagnosed with DID, 11 had suffered severe abuse, even torture, in childhood (Lewis et al., 1997). One had been set afire by his parents. Another had been used in child pornography and was scarred from being made to sit on a stove burner. Some critics wonder, however, whether vivid imagination or therapist suggestion contributes to such recollections (Kihlstrom, 2005).

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So the debate continues. On one side are those who believe multiple personalities are the desperate efforts of people trying to detach from a horrific existence. On the other are the skeptics who think DID is constructed out of the therapist-client interaction and acted out by fantasy-prone, emotionally vulnerable people.

There is little debate about the reality of personality disorders. These inflexible and enduring behavior patterns interfere with a person’s ability to function socially. Some people with these disorders are anxious and withdrawn, and they avoid social contact. Some behave in eccentric or odd ways, or interact without engaging emotionally. Others seem overly dramatic or impulsive, focusing attention on themselves.

The most troubling and heavily researched personality disorder is antisocial personality disorder. People with this disorder are typically males whose lack of conscience becomes plain before age 15, as they begin to lie, steal, fight, or display unrestrained sexual behavior (Cale & Lilienfeld, 2002). They behave impulsively and then feel and fear little (Fowles & Dindo, 2009). Not all children with these traits become antisocial adults. Those who do (about half of them) will generally act in violent or otherwise criminal ways, be unable to keep a job, and, if they have a spouse or children, behave irresponsibly toward them (Farrington, 1991). People with antisocial personality (sometimes called sociopaths or psychopaths) may show lower emotional intelligence—the ability to understand, manage, and perceive emotions (Ermer et al., 2012).

Antisocial does not necessarily mean criminal (Skeem & Cooke, 2010). When lack of conscience combines with keen intelligence, the result may be a charming and clever con artist—or a fearless and ruthless soldier, CEO, or politician (Dutton, 2012).

But do all criminals have antisocial personality disorder? Definitely not. Most criminals show responsible concern for their friends and family members.

Understanding Antisocial Personality Disorder

Antisocial personality disorder is woven of both biological and psychological strands. No single gene codes for a complex behavior such as crime. There is, however, a genetic tendency toward a fearless and uninhibited life. Twin and adoption studies reveal that biological relatives of people with antisocial and unemotional tendencies are at increased risk for antisocial behavior (Frisell et al., 2012; Tuvblad et al., 2011).

Genetic influences and negative environmental factors (such as childhood abuse, family instability, or poverty) can work together to help wire the brain (Dodge, 2009). The genetic vulnerability of those with antisocial and unemotional tendencies appears as low arousal. Awaiting events that most people would find unnerving, such as electric shocks or loud noises, they show little bodily arousal (Hare, 1975; van Goozen et al., 2007). Long-term studies show that their stress hormone levels were lower than average as teenagers, before committing any crime (FIGURE 13.15). And those who were slow to develop conditioned fears at age 3 were also more likely to commit a crime later in life (Gao et al., 2010).

Other brain activity differences appear in studies of antisocial criminals. Shown photographs that would produce an emotional response in most people (such as a man holding a knife to a woman’s throat), antisocial criminals’ heart rate and perspiration responses are lower than normal, and brain areas that typically respond to emotional stimuli are less active (Harenski et al., 2010; Kiehl & Buckholtz, 2010). Other studies have found that people with antisocial criminal tendencies have a smaller-than-normal amygdala, an emotion-controlling part of the brain (Pardini et al., 2014). They also display a hyper-reactive dopamine reward system that predisposes their impulsive drive to do something rewarding, despite the consequences (Buckholtz et al., 2010).

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One study compared PET scans of 41 murderers’ brains with those from people of similar age and sex. The murderers’ frontal lobe, an area that helps control impulses, displayed reduced activity (Raine, 1999, 2005). This reduction was especially apparent in those who murdered impulsively. In a follow-up study, researchers found that violent repeat offenders had 11 percent less frontal lobe tissue than normal (Raine et al., 2000). This helps explain another finding: People with antisocial personality disorder fall far below normal in aspects of thinking such as planning, organization, and inhibition, which are all frontal lobe functions (Morgan & Lilienfeld, 2000). Such data remind us: Everything psychological is also biological.