their peers was one of the factors that predicted dysfunctional eating attitudes 2 years later (Westerberg et al.,2008).
Children and adolescent who are dissatisfied with their body image or who have body image distortion are at increased risk for developing an ED (Zoletic and Durakovic-Belko, 2009; Lukacs-Marton et al.,2008; Dupont and Corcos, 2008;
Rome et al., 2003). In a study of women with AN, Pike et al. (2008) demon- strated that concerns about weight and body shape were most important in the year before onset of the ED. Dupont and Corcos (2008) suggest that individu- als’ body dissatisfaction and responses to food and eating are incorporated into their patterns of unstable relationships with their parents. These relationships alter- nate between feelings of merging and rejection and feelings of being engulfed and remote.
Children and adolescents who are teased, bullied, or sexually harassed about their body weight, size, and shape by their friends, acquaintances, and others may be more likely to develop dysfunctional weight control behaviors and weight- associated attitudes and acquire EDs (Eisenberg and Neumark-Sztainer, 2008;
Neumark-Sztainer et al.,2002; U.S. DHHS,2000). Using data from a population- based study of weight issues and eating patterns among teens, Neumark-Sztainer et al. (2002) demonstrated that perceived weight-teasing was significantly corre- lated with disordered eating among both overweight and non-overweight girls and boys. Girls and boys who experienced frequent weight-teasing were more likely to report binge eating (BE) (29 and 18%, respectively) than by girls and boys who did not report weight-teasing (16 and 7%, respectively).
In an investigation of male and female adolescents by Libbey et al. (2008), frequent teasing by family members and peers was related to more disordered eat- ing thoughts and behaviors, symptoms of depression, anxiety, anger, and lower self-esteem. Adolescents who disliked being teased about their weight were more likely to value thinness, and their self-evaluation was affected by their body weight and shape. Victims who were teased frequently and negatively responded to such harassment were more likely to favor severe forms of BE and have symptoms of depression.
Peer harassment, including bullying and teasing, increases the chances that the victims will acquire other forms of dysfunctional weight-related attitudes. For exam- ple, victims of peer harassment are more likely to be dissatisfied with their body weight and shape (Eisenberg and Neumark-Sztainer,2008).
Body-image dissatisfaction may increase the probability of suicidal ideation dur- ing adolescence (Kim and Kim,2009; Rodriguez-Cano et al.,2006). Drawing on longitudinal data from the Korea Youth Panel, Kim and Kim (2009) demonstrated that body-image dissatisfaction was associated with an increased risk of suicidal ideation in early-adolescent girls and mid-adolescent boys. The authors suggest that interventions should be tailored to the gender and adolescent stage to reduce risk of suicide in these populations.
A community-longitudinal investigation by Rodriguez-Cano et al. (2006) showed that prior suicidal thinking and scores on the Body Shape Questionnaire increased the probability of reported suicide attempts in the next 2 years.
Etiology and Risk Factors 175 Children and adolescents who have a history of excessive dieting and fre- quently miss meals and engage in compulsive exercise may be at increased risk of developing EDs (Rome et al.,2003).
In terms of other psychosocial factors, various dysfunctional eating attitudes, low self-esteem, the inability to develop a well-developed identity, problems with attach- ment, and dependency resulting from poorly internalized relationships are thought to cause EDs (Westerberg et al., 2008; Rome et al., 2003; Dupont and Corcos, 2008; Cozzi and Ostuzzi,2007; Stein and Corte,2007). AN and BN may repre- sent attempts to cope with the failure of defense mechanisms and problems with psychological organization (Dupont and Corcos,2008).
A longitudinal investigation of disturbed eating attitudes in adolescent girls revealed that children’s eating attitudes was on the conditions that predicted dis- turbed eating attitudes 2 years later (Westerberg et al.,2008). The frequency of dysfunctional eating attitudes increased with increased age in the adolescent girls.
Perfectionism and obsessive–compulsive (OC) personality traits may increase the risk of ED in childhood and adolescence (Zoletic and Durakovic-Belko,2009;
Halmi et al.,2005; Anderluh et al.,2003; Rome et al.,2003). Using a case–control study design, Anderluh et al. (2003) showed that childhood obsessive personal- ity traits predicted the subsequent onset of EDs. The investigators discovered that individuals with EDs who exhibited perfectionism and rigidity during childhood were more likely to develop obsessive–compulsive personality disorder (OCPD) and obsessive–compulsive disorder (OCD) later in life than those persons with an EDs who did not have those traits.
Participation in various sports, such as ballet, gymnastics, fashion modeling, and horse racing, are risk factors for acquiring EDs (Lukacs-Marton et al.,2008;
Zoletic and Durakovic-Belko,2009). Based on a sample of fashion models from Transylvania, Lukacs-Marton et al. (2008) discovered that fashion models used more weight-reducing methods, scored higher on Dieting and Bulimia subscales of the Eating Behaviour Severity Scale, and exhibited more body dissatisfaction than control groups.
Another investigation of female ballet dancers and models by Zoletic and Durakovic-Belko (2009) found that female ballet dancers and models showed more body image distortion, eating disorder behaviors, and symptoms of neurotic perfectionism than a control group of students from the University of Sarajevo.
Halmi et al. (2005) evaluated the relation among perfectionism, OCPD, and OCD in persons with EDs. They discovered that perfectionism is more closely related to OCPD symptoms than OCD among individuals with AN and BN. They suggest that the pairing of perfectionism and OCPD increases one’s risk for EDs.
Affective disorders are linked to EDs (Fernandez-Aranda et al., 2007).
Researchers have found that major depression is a risk factor for EDs among adolescents (Rome et al.,2003; Strober and Katz,1988; Patton et al.,1999).
Researchers have analyzed the symptoms of major depressive disorder (MDD) in women with EDs. Almost 73% of the women had a lifetime prevalence of MDD.
Almost 35% of those women with a lifetime prevalence of MDD reported the onset of MDD before the onset of ED. Women who reported the onset of MDD
before the onset of ED exhibited more psychomotor agitation and thoughts about their own death (but not suicide attempts or ideation). Among the women who had MDD onset before ED onset, 26.5% had the MDD onset in the year prior to ED onset.
Children and adolescents with anxiety disorders appear to be at increased risk of developing EDs. Kaye et al. (2004) found that among persons with AN and BN, the rates of anxiety disorders in general and OCD in particular was significantly higher than in a non-clinical community sample of women. The authors reported that among persons with EDs, approximately two-thirds had one or more lifetime anxiety disorders, with the most prevalent ones were OCD and social phobia. Most of those studied developed OCD, social phobia, specific phobia, and generalized anxiety disorder in childhood before acquiring an ED.
Children and adolescents with a history of childhood trauma, such as child- hood abuse (e.g., sexual, physical, and emotional abuse, and neglect), may be at increased risk of developing an ED (Rome et al.,2003; Corstorphine et al.,2007;
Svirko and Hawton,2007; Rayworth et al.,2004). In a study of persons with an ED, Corstorphine et al. (2007) showed that those with a history of childhood trauma were more likely to report impulsive behaviors. Those individuals with ED with a history of childhood sexual abuse had a higher probability of engaging in self-cutting, alco- hol abuse, and other substance abuse, including amphetamines, cocaine, cannabis, and ketamine, than those without a history of childhood sexual abuse.
In addition to childhood abuse in the family setting, family conflict may be a risk factor for the development of certain types of EDs (Skarderud and Sommerfeldt, 2009; Pike et al.,2008). Pike et al. (2008) discovered that women with AN had a higher rate of family conflict compared to women with non-EDs. A high degree of family conflict and other factors, such as impulsivity, OC symptoms, and dissocia- tive states, may be more likely to predict the onset of self-harm among patients with BN and AN binge type than among patients with the AN restrictive type (Skarderud and Sommerfeldt,2009).
Other investigators have found a strong positive association between self- harm behaviors and EDs, indicating that self-harm may be a risk factor for EDs (Skarderud and Sommerfeldt,2009; Corstorphine et al.,2007). According to Skarderud and Sommerfeldt (2009), the reported prevalence of self-harm among patients with EDs has ranged from 13 to 68%. Patients with BN and the binge- type AN have had higher rates of self-harm than patients with AN restrictive type. Common factors related to both self-harm behaviors and these EDs may include impulsiveness, OC traits, dissociation, trauma, and substantial family conflict.
Childhood abuse may increase the risk of body dissatisfaction, depression, low self-esteem in persons, alcohol and drug abuse, and self-harm with EDs (Corstorphine et al.,2007; Grilo and Masheb,2001). In one study of outpatients with BED, different types of childhood maltreatment were linked to different psy- chosocial problems (Grilo and Masheb,2001). Among men and women with BED, a history of childhood emotional abuse was associated with increased body dissat- isfaction, higher depression, and lower self-esteem. Childhood sexual abuse was
Etiology and Risk Factors 177 related to increased body dissatisfaction among men with BED. However, the authors did not find an association between any form of childhood maltreatment and age of onset of overweight, dieting, or BE behaviors in this sample of men and women with BED.
Other family characteristics, behaviors, and dynamics may increase the risk of developing EDS (Rome et al.,2003). Children and adolescents who are teased about their body by their family members may be at increased risk of developing EDs. In a study of middle school girls, Keery et al. (2005) discovered that girls who reported that they had been teased about their body appearance by at least one sibling expe- rienced greater body dissatisfaction, internalization of the thin ideal, restriction, bulimic behaviors, depressive symptoms, and lower self-esteem compared to girls who had not reported being teased by their siblings. Increased frequency of teasing was related to worse outcomes.
Higher parental demands may increase the likelihood of AN and other EDs. In a case–control study of women with AN, Pike et al. (2008) identified higher parental demands as a possible risk factor for the onset of AN.
In a Swedish study, Ahren-Moonga et al. (2009) demonstrated that the higher levels of parental and grandparental education and higher academic performance may result in an increased risk of hospitalization for EDs among female offspring.
The authors suggest that female offspring may be at increased risk because of high internal and external demands.
Research offers evidence of familial transmission of risk for EDs (Wagner et al., 2008; Rome et al.,2003; Strober et al.,2000). Case–control investigations reveal a higher prevalence of AN among relatives of probands who have AN. Moreover, rate of BN is higher among relatives of AN probands. Strober et al. (2000) suggest that the increased rates of AN and BN among families may be due to several factors, including the co-occurrence of BE and AN, similar patterns of gender and personal- ity characteristics among persons who have both disorders, and the fact that persons with AN and BN often suffer from mood and anxiety disorders.
The risk of acquiring AN is different from that of other affective disorders even though AN and major depression may have shared origins (Rome et al., 2003).
An important caveat is that depression occurs because of starvation, and many symptoms can be improved when weight is restored.
In a German study, Wagner et al. (2008) showed that the rates of AN and MDD were higher among first- and second-degree relatives of AN and bulimic individuals, compared to the relatives of healthy controls. The trends were more evident among the relatives of bulimic patients.
A family history of an ED or obesity is a risk factor for ED (Rome et al.,2003). In addition, parental eating behavior, weight, and eating-related attitudes may help to predict the onset of EDs in children and adolescents (Canals et al.,2009; Westerberg et al.,2008; Rome et al.,2003).
Canals et al. (2009) evaluated the influence of parent’s eating attitudes on EDs in school adolescents and showed that the mother’s body dissatisfaction, drive for thin- ness, and the father’s drive for thinness and perfectionism were positively associated with the adolescent’s long-term ED.
In a 2-year longitudinal investigation, Westerberg et al. (2008) discovered that fathers’ eating attitude was one of the factors that predicted disturbed eating attitudes among adolescent children 2 years later.
Substance use disorders are common among individuals with EDs and their fam- ilies. For example, among women with BN and their family members, substance use disorders are prevalent (Kaye et al.,1996). Studies have found that affective disorder, substance dependence, including alcoholism, in first-degree relatives is a risk factor for EDs (Redgrave et al.,2007; Rome et al.,2003; Kaye et al.,1996).
Based on an investigation of female inpatients at a specialty ED service, Redgrave et al. (2007) discovered that inpatients with alcoholic first-degree relatives had more ED-related psychopathology, substance use, vulnerable personality characteristics, compared to those without alcoholic first-degree relatives.
Parent–child communications may play a role in the onset of EDs (Kim and Yang,2008). A study of the relationship between EDs and parent–adolescent com- munication revealed that EDs were more likely in adolescents who had reduced parent–adolescent communication (Kim and Yang,2008).
Characteristics of school experiences may increase the risk of EDS and other problems among certain individuals. Boujut and Bruchon-Schweitzer (2009) devel- oped a college freshman stress questionnaire and discovered that EDs, symptoms of depression, somatic symptoms, and life satisfaction were correlated with academic stress, university functioning, feeling lonely, and having difficulties with primary relations.
The characteristics of certain occupations and industries, such as fashion mod- eling, ballet, and sports, may increase the likelihood that those working in these occupations and industries will acquire EDs (Lukacs-Marton et al.,2008; Zoletic and Durakovic-Belko,2009).
Some scientists suggest that physiologic factors cause EDS. Some theorize that dysfunctional pituitary, hypothalamus, and different neurotransmitters lead to the onset of EDs (Rome et al., 2003). However, functional imaging studies show that these physiological processes are corrected when the persons achieve normal weight, suggesting that these physiological processes are not primary etiological factors.
Other investigations have evaluated the role of serotonin in the etiology of EDs since the neurotransmitter serotonin influences the control of appetite, sex- ual and social interactions, and responses to stress and mood (Rome et al.,2003).
A reduction in brain serotonin function is linked to psychosocial problems, such as depression, impulsive behavior, and aggression. In persons with AN who are underweight, the serotonin metabolite, 5-hydroxyindoleacetic acid, is at a low level.
However, after these individuals have returned to long-term normal functioning, the metabolite increases to above normal levels.
Research has led to the speculation that impaired serotonergic function may increase the risk of AN and BN (Rome et al.,2003). An allelic association between the B1438 A/G promoter polymorphism of the 5-HT2A gene and AN has been found, but the findings have not been replicated consistently.